Sclerotherapy

*** please note that the dose of the Calcitonin and Depo-Medrol is always the same, but some of the other volumes may change depending on the size/volume of the lesion. When evaluating the lesion, try to measure/calculate an approximate volume on cross sectional imaging ***

Materials:

• Calcitonin 200 IU 1 mL (Figure 1)

  • Order on Epic

  • Have to call pharmacy after patient arrives and ask them to tube it to station 29 (in the RICA)

  • Touch base with the nurse to let them know the medication is coming

• Depo-Medrol 80 mg 2 mL

  • Get this from the Yawkey 6 procedure area

• Isovue-M-300 (any iodinated contrast is ok) 2-5 mL (depends on the volume of the lesion)

• Albumin 25% 5 mL (Figure 2) (optional, depends on the volume of the lesion) - ask Connie if this is necessary); this is ordered through Epic but the nurse has it on hand in the department.

• Normal saline 2 mL (depends on the volume of the lesion) - make sure it is INJECTABLE saline (easier to get from Y6 procedure area). The stuff poured from the bottles onto the tray is NOT for injection (only for irrigation)

• 3 way stop cock

• 20 mL syringe(s) - for aspiration and mixing

• 10 mL syringe 

  • 1 for injection

  • May need additional syringes for aspiration

• OnControl for most cases

• Chiba 22 G, long enough to extend through the introducer of the OnControl

Consent

• Multiple access points

• Multiple treatments (often requires more than one for complete treatment)

• Frozen

Procedure:

1. Prepare CT fluoro

2. If biopsy has already been performed, skip to Step 6

3. After scanning, choose the approach that will allow the most number of chambers to be accessed. Remember they often communicate, which is why we inject contrast (to see where they go)

4. Anesthetize the periosteum using 2 mL of lidocaine. Wait 5 minutes for the 

5. Access the desired area with the introducer

6. Biopsy the lesion - choose the area that is most nodular/appears most like tumor

7. Confirm that the lesion is not secondary ABC or malignancy on frozen

8. Aspirate through the introducer using the 10 mL or 20 mL syringes. If the total aspirated volume reaches 50 mL, stop aspirating. The bleeding inside the ABC is probably so fast that the bleeding into the lesion outpaces the aspiration.

9. Record the volume of volume aspirated and document the volume in the report.

10. Access the chamber with Chiba (Note, occasionally, if the lesion is large, we may access the lesion from two points using the OnControl)

11. (This mixture may change depending on the size of the lesion. Some lesions are small (<<20 mL)) In the 20 mL syringe, draw up:

    1. 1 mL calcitonin

    2. 2 mL Depo-medrol

    3. 2 mL normal saline

    4. 5 mL albumin

    5. 5 mL contrast

12. In the 10 mL syringe, draw up 5 mL of air (optional)

13. Set up the 3 way stop cock with the 20 mL syringe and the 10 mL syringe

14. Close the 3 way stopcock to the side with no syringe. Agitate the contents of the 20 mL and 10 mL syringes by going back and forth between the two to create the sclerosant foam

15. Put 5 mL of the sclerosant foam into the 10 mL syringe and close the 3 way stopcock to the 20 mL syringe.

16. SLOWLY (so you barely feel like you're moving) inject the sclerosant foam from the 10 mL syringe into the Chiba (easier to control the volume injected using the 10 mL syringe. You can also gently tap the plunger to incrementally and slowly inject). You will see blood decompress out of the sides of the Bonopty. When the decompressing blood turns pink or foamy white, stop injecting. Wait a few moments until it turns into blood again, and then try to inject more. Sometimes if you give the medication a little time to sink in the 

17. Record the volume of sclerosant injected and document the volume in the report.

18. Perform a longer scan (using regular CT, not just CT fluoro) to check to see where the contrast has flowed into. Often the chambers can communicate and contrast will be seen quite far from the injection site.

19. If needed, access other sites, and repeat until procedure is completed

Figure 1 - Calcitonin

Figure 2 - Albumin

Figure 3 - Injection tubing - I no longer use this and just direct inject