(1) Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M, Karnabatidis D. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 2018;7(24):e011245-e011245. 

(2) MHRA statement : Paclitaxel drug-coated balloons (DCBs) or drug-eluting stents (DESs): Reconfirmed position on use in patients with intermittent claudication and critical limb ischaemia (DSI/2021/001) Paclitaxel drug-coated balloons (DCBs) or drug-eluting stents (DESs): Reconfirmed position on use in patients with intermittent claudication and critical limb ischaemia (DSI/2021/001) - GOV.UK (www.gov.uk)

A lymphatic malformation is an abnormality of the lymphatic system that results in a collection of fluid filled spaces. These malformations are congenital (they were present when you were born). The cysts are filled with a clear fluid, similar to the fluid in a blister. Lymphatic malformations are not dangerous but can cause pain and swelling. 

Microcystic malformations contain lots of tiny cysts and usually cause problems because they are bulky, unsightly, or get infected. Sclerotherapy is a way of trying to reduce the size of the cysts so that they are smaller and less troublesome.
 

A venous vascular malformation is a collection of abnormal venous vascular spaces. These spaces will have some connections to nearby normal veins. 

Venous malformations are congenital (they were present when you were born). They contain vascular spaces with slow flowing blood and solid tissue.

Like lymphatic malformations venous vascular malformations are not usually dangerous, but can cause pain and swelling, particularly when blood clots form within the lesion. 

Bleomycin is a medicine that has been used for many years to treat other conditions such as cancer. More recently small doses of bleomycin have been found to be useful for treating vascular and lymphatic malformations. 

When it has been used in higher doses in cancer treatment and has been injected straight into the bloodstream, bleomycin can cause damage and changes to the lungs and how they function. This can happen during the treatment or afterwards. This is extremely unlikely to happen when bleomycin is being used in sclerotherapy, as the doses are much lower, and the medicine is not given in the same way.

However, always tell your doctor if after treatment with bleomycin you: 

• Develop a wheeze.
• Develop a cough.
• Have a fever.
• Feel breathless.

You should also let them know if any existing breathing problems get worse.

Before you attend for bleomycin sclerotherapy we will send you a clinic appointment to meet with the radiologist. Here they will assess your suitability for the procedure.

If necessary, we will arrange for you to have some breathing tests before you have bleomycin treatment.

You will need to have a blood test a few days before the procedure to check that you are not at increased risk of bleeding and that it will be safe to take to proceed with the bleomycin treatment. This may be arranged to take place at your GP surgery. 

You can continue taking your normal medication. If you are on any medication which thins the blood (e.g., aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran, apixaban) please call the Imaging Department using the number on your appointment letter as we may need to adjust your medication.  

• You should not eat anything from midnight the night before the procedure. You may drink clear fluids until 7am on the day of the procedure. 
• You will arrive at the Imaging Department, Gate 19, and be accompanied into our day case area. 
• You may take your normal medication unless instructed otherwise.
• Please inform us if you are allergic to anything. 
• The radiologist will discuss the procedure with you. You will be given an opportunity to ask questions. If you want to go ahead with the procedure you will be asked to sign a consent form.
• You will be asked to change into a hospital gown and a small plastic tube (cannula) may be put into your arm.
• Once all the checks have been performed and consent signed, you will be taken to the X-ray room on the trolley. There will be a radiologist, nurses and a radiographer with you throughout the procedure.
• The radiologist will use an ultrasound machine to look at the malformation to find the correct area to be treated.
• Your skin will be cleaned with an antiseptic solution and covered with sterile drapes. 
• The radiologist will then inject local anaesthetic into the area selected, which will briefly sting and then go numb. The radiologist may then inject X-ray dye into the malformation to confirm the needle position and that it is safe to inject bleomycin. The bleomycin will then be injected through one or several small needles into the malformation under ultrasound and sometimes X-ray guidance. 
• The procedure is likely to take about 30 minutes.
• Once the procedure is complete the needle(s) will be removed, and the radiologist will apply a dressing if necessary. 

• You will be taken back to the day case area, so that nursing staff may monitor you closely.
• If you are in pain, tell the nursing staff so you can be given appropriate painkillers.
• You will be advised to stay in our day case area for up to 4 hours.
• You will be able to eat and drink as normal.
• If everything is satisfactory, you will be free to go home. 

Bleomycin sclerotherapy is usually a safe procedure. Potential complications include:

• In the first 24 hours following bleomycin sclerotherapy, the area is likely to be swollen. You may take over the counter pain medication as necessary to keep the inevitable associated pain under control. The pain will resolve within a few days, but it may take several weeks for the swelling to settle completely.
• There is a slight risk of the malformation developing an infection after the treatment. You will need a short course of oral antibiotics if this happens.
• Very rarely, bleomycin can cause some discolouration of the skin or nails or make some hair fall out. This usually gets better with time. We think that the skin is more likely to be affected if there are monitoring leads or plasters stuck to the skin at the time of treatment. We will try to put these on parts of the skin that are less noticeable.
• In some cases, when bleomycin has been used in much higher doses straight into the bloodstream for treating cancers, patients have developed scarring of their lungs, causing breathing problems. This has only been reported for high dose treatment with bleomycin, not at the doses used for sclerotherapy of vascular malformations. 
• If the bleomycin spreads beyond the malformation it may cause damage to nearby normal tissues. 
  This is a rare complication but can cause permanent damage to the affected tissues. One example could be damage to the overlying skin which may ulcerate and cause scarring of the area. Other structures that could be affected depend on where in the body the malformation is, but could include muscle or nerve damage which may be permanent. 

If you experience any symptoms you are concerned about, please contact the Imaging Department directly on the number on your appointment letter or alternatively contact your GP or the Emergency Department.

Sclerotherapy is the best treatment option for many malformations as it can be an effective treatment and usually carries lower risks than open surgery. However, as every malformation is different, sclerotherapy may not always be the best option. 

Alternative options may include having no treatment, surgery or a combination of surgery and sclerotherapy. Your doctor will explain the options for treatment suitable for you.

You might need several sclerotherapy procedures to reduce the malformation. Sclerotherapy will not ‘cure’ the malformation, but it should shrink it significantly. 

We will also review you at an outpatient clinic appointment around 2 - 3 months after treatment.

Again, if you experience any symptoms you are concerned about, please contact the Imaging Department directly on the number on your appointment letter or alternatively contact your GP or the Emergency Department.

Finally, we hope this information is helpful. If you have any questions either before or after the procedure the staff in the Imaging Department will be happy to answer them.

NICE | The National Institute for Health and Care Excellence

Bleomycin sclerotherapy | Great Ormond Street Hospital (gosh.nhs.uk)

Vascular Malformations | BSIR

Intralesional bleomycin injection - South Tees Hospitals NHS Foundation Trust

These are high protein foods. They are essential:

• For strong muscles.
• To fight off infections.
• For healthy skin and blood.

Before starting dialysis, you may have been advised to eat smaller portions of protein foods. Now your body is losing some protein during dialysis. You need to eat extra protein foods to replace what you are losing.

These are high protein foods:

Milk, cheese, yoghurt and fortified soya milk are great sources of protein and calcium. They also contain a lot of phosphate.

Phosphate levels in the blood may be high when the kidneys are not working properly; this can increase your risk of heart disease, cause weak bones and itching. Your dietitian will advise if you need to limit these foods to lower phosphate levels in the blood. See page 10 for more information about phosphate.

These foods give us energy. 

Try to include one serving at every meal. 

Wholegrain varieties are high in fibre. Fibre helps to keep your bowels healthy and prevent constipation. Constipation can prevent your dialysis from working well.  Try to choose these wholegrain foods:

• Wholemeal or granary bread.
• Wholegrain cereals such as shredded wheat or Weetabix.
• Wholewheat pasta.
• Brown rice.

You may have been advised to always boil potatoes, yam, cassava and plantain; this reduces the potassium. Your dietitian will advise you if you still need to do this.

Eat at least five portions of a variety of fruit and vegetables per day. 

You may have been advised not to eat some fruit and vegetables because your potassium levels in the blood have been high.

Your dietitian will advise you if you still need to do this.

Foods high in fat and/or sugar include pastry, fried foods, cakes, biscuits and chocolate.  

Dialysis fluid usually contains glucose (a form of sugar). Some of this glucose will get into your blood and give you extra calories which may cause unwanted weight gain.  

If your appetite is good and you want to manage your weight and eat to keep your heart healthy, you could:

• Eat smaller portions of high fat/high sugar foods.
• Choose low fat options where possible such as lean meats.
• Choose lower fat dairy foods such as milks, yoghurts and cheeses.
• Use smaller amounts of unsaturated fats and oils such as vegetable oil and olive oil spread.

Fluid mainly comes from liquids you drink.

When most people start dialysis, they are still passing urine. Fluid is removed from the body by dialysis and by passing urine. Many people find that after a while on dialysis they pass less urine; they begin to rely on dialysis to remove most of the fluid.

If you are drinking more fluid than can be removed, you will become fluid overloaded (oedema).  The extra fluid puts a strain on your heart and lungs. It is often difficult to remove extra fluid by dialysis.

Signs you are overloaded are:

• Rapid weight gain.
• Swollen ankles.
• Feeling breathless.
• Higher blood pressure.

Weigh yourself daily and this helps you quickly notice rapid weight changes due to fluid.

If you are gaining too much fluid your doctor, dialysis nurse or dietitian may advise you to limit the fluid you drink.

Tips if you need to have less fluid:

• Try to have fewer drinks and spread your fluid throughout the day.
• Use a small cup or glass for drinks.
• If eating sloppy or liquid foods such as such as soup, custard, yoghurt, ice-cream, reduce how much you drink.
• Spicy and salty foods can make you thirsty so try to reduce these foods.
• Try using plastic ice cubes in drinks to save extra fluid.
• Rinsing your mouth, gargling with mouthwash and brushing your teeth can help freshen your mouth.
• You can quench your thirst with slices of lemon, orange, frozen grapes, pineapple cubes, boiled sweets, sugar free mints and chewing gum.
• If you have a dry mouth, artificial saliva sprays may help such as Glandosane (available on prescription).
• Keep a record of all liquids you are having including all drinks, soups, gravies, jelly, yoghurts, and ice-cream.

Your dietitian can give you more ideas to help.

Eating less salt can help you to feel better. Reducing salt helps your dialysis remove fluid, can improve your blood pressure and make you feel less thirsty. Most of the salt we eat comes from processed and ready prepared foods. Tips to reduce salt:

• Have more home cooked foods. Cook from scratch where you can.
• Try to reduce processed foods. Sausages, bacon, ham, ready meals, jars of mustard, sauces, pickles, and table sauces are salty.
• When shopping, check food labels. Aim to eat mainly foods which have less than 0.3g salt per 100g or with a green traffic light symbol for salt. If you are choosing ready meals, aim for less than 1.8g per portion.
• Consider having higher salt foods (more than 0.3g salt per serving, or amber or red traffic light) less often and in smaller amounts.
• Free apps such as FoodSwitch or NHS Food Scanner can help.
• Flavour your food with herbs, spices, lemon, garlic, vinegar, dry mustard powder.
• Try to avoid using salt in cooking. Taste food first as you may not need it.  
• Try not to add any salt at the table.
• Avoid salt that has ‘low in sodium’ written on the label as these contain potassium. This includes LoSalt, Solo, Saxa So-low.

Your dietitian can give you more help to reduce the salt you eat.

Potassium is a mineral found in many foods. It helps our nerves, muscles and heart to work properly. Our kidneys usually control the level of potassium in the blood. Extra potassium is passed out in the urine.  

Dialysis removes potassium but you may still have high levels in the blood, especially if you start to pass less urine or have problems with dialysis. Your levels of potassium in your blood will be checked regularly.  

The target range for potassium in your blood is 3.5 – 5.4mmol/l. A high level of potassium can be dangerous, as it can affect your muscles and heart.  

Your dietitian will advise if you need to eat less potassium to keep your blood levels safe.      

These are foods and drinks higher in potassium:

• Some fruits such as apricots, avocado, bananas and dried fruit.
• Some vegetables such as mushrooms, parsnips, spinach and tomatoes.
• Potatoes which have not been boiled such as chips and jacket potatoes.
• Snacks such as potato crisps, nuts, chocolate and liquorice.
• Drinks such as coffee, malted milk drinks and fruit juices.
• Alcoholic drinks such as cider and strong ales.
• Soups containing tomatoes and vegetables.
• Salt substitutes such as Losalt, Saxa So low and Solo.
• Only limit high potassium foods if you have been advised to.

If you have diabetes, you may have been recommended to eat more fruit, vegetables and nuts. Your dietitian can advise you on appropriate quantities and help you choose lower potassium options. 

Rarely blood potassium levels may be too low. Your dietitian will advise you what to eat to help with this.

Phosphate levels in the blood can be high when the kidneys are not working properly; this can increase your risk of heart disease, weaken your bones and cause itching.  

Dialysis is poor at removing phosphate from the blood. Your levels of phosphate in your blood will be checked regularly.  

The target range for phosphate in your blood is 0.8 – 1.5mmol/l. If your levels are high, eating less phosphate can protect your bones and heart, and help you feel less itchy.  

High phosphate food and drinks include:

• Cola drinks and other dark coloured fizzy drinks which contain phosphoric acid.
• Processed foods containing phosphate additives such as ready meals, processed meats and cake mixes. Check the ingredients label for additives with ‘phosphate’ in the name such as diphosphates, triphosphates, sodium phosphate.
• Nuts and chocolate.
• Products with raising agents such as muffins and scones.
• Malted milk drinks, drinking chocolate and cocoa.
• Evaporated and condensed milk.
• Fish with edible bones such as sardines, pilchards and whitebait.
• Shellfish such as fresh crab and scampi.
• Offal products such as liver, liver sausage and pate.

Other high phosphate foods such as dairy products, milk, fish and meat are good sources of protein and other nutrients.  Some recommended portion sizes are below. 

Your dietitian can guide you on how many servings to have per day or per week. For most people 2 servings per day of dairy foods and up to 6 eggs per week will limit the amount of phosphate you’re eating. 

If you are already following a low phosphate diet your dietitian will advise if you need to continue. Only limit high phosphate foods if you have been advised to.

To help control phosphate levels, some people may be prescribed tablets called phosphate binders. Your dietitian will advise on the best way to take these to make sure they work well.

If you have peritonitis you will lose more protein than usual through the dialysis process. Eating extra protein foods at this time will help your recovery. Ask your dialysis nurse or renal dietitian for advice. The information below may help if your appetite is reduced.

If you have a small appetite, the following information may help:

• Eat little and often throughout the day.  Try three meals and 2 - 3 snacks every day.
• Eat small nourishing snacks between meals such as cereal and milk, cheese and biscuits, cakes, biscuits, desserts, pastries.
• Have a snack, sandwich or a milky drink if you cannot manage your normal meal.
• Try easy to prepare high protein meals such as cheese, scrambled egg, poached egg on toast or omelette.
• Use full fat and full sugar versions of foods and drinks such as full fat milk, full fat yoghurt instead of diet or low fat ones.
• Try to eat more on days or at times you feel better.
• Spread butter, margarine, honey, jam and marmalade thickly on bread, croissants, and crumpets.
• Add honey or sugar to cereals and puddings.

Eating well is important to help you feel better and cope with dialysis.  

Some of these foods are high in salt, sugar, phosphate and potassium which may not be in line with the diet you have previously been advised to follow. If you have diabetes or you are limiting potassium or phosphate speak to your dietitian for more information.

Water soluble vitamins are lost during the dialysis process. 

Your GP can prescribe a multivitamin tablet (Renavit) suitable for people with kidney disease; this helps to replace the vitamins lost during dialysis.  

Renavit contains a beef product so if you are unable to take this, we can recommend an alternative.

You will need to take Renavit once a day.

Many people want to eat food that is more environmentally friendly.

Below are some ideas you could consider:

• Try some plant food sources of protein such as beans, lentils, soya mince, Quorn, tofu.
• When buying fish look for the Marine Stewardship Council or Aquaculture Stewardship Council symbols.
• Try calcium fortified plant milk such as soya or oat instead of cow’s milk.
• Opt for wholemeal breads and wholegrain versions of pasta and cereals.
• Choose local and seasonal produce.
• Avoid chopped, ready prepared and packaged fresh fruit, veg and salads if you can.
• Reduce food waste, especially of fresh fruit and veg, by choosing tinned and frozen alongside seasonal fresh produce.

Patients Know Best is an easy-to-use online service that allows you to monitor your own blood test results.
Register to Patients Know Best - Patients Know Best

Information on kidney disease and food written by the kidney dietitians at North Bristol NHS Trust.
Nutrition & Dietetics | North Bristol NHS Trust (nbt.nhs.uk)

Education videos on how to eat less salt presented by the Kidney dietitians at North Bristol NHS Trust.
Educational videos on salt for kidney patients - YouTube 

Diet and lifestyle information including recipe books to download.
Living with kidney disease | Kidney Care UK

Diet information including menus and recipe books to download.
Kidney Patient Guide - Diet

Website of the Edinburgh Renal Unit and contains useful dietary information.
Diet in renal disease – edren.org
 

Foods that weigh more than 100g can be labelled per portion. Please check the suggested portion is the same as the amount you plan to eat.

Where possible, try to avoid foods with more than 1.8g of salt per portion.

Salt is 0.6g/100g which is medium (amber). 

Salt is 1.51g/100g which is high in salt (labelled red). 

Meals eaten away from the home are often high in salt. If you know you will be eating out, try to choose lower salt options for other meals and snacks eaten that day.

• Feta, halloumi and blue cheese. If you eat a lot of moderately high salt cheese such as cheddar, try lower salt alternatives such as cream cheese and cottage cheese
• Salted butter (try margarine or unsalted butter).
• Cured meats such as bacon, ham, gammon, salami, chorizo, Parma ham, serrano ham, salt beef. 
• Tinned and processed meats such as corned beef, luncheon meat, spam, sausages, black pudding. • Smoked fish (haddock, mackerel, salmon) and shell fish.
• Tinned vegetables, sundried tomatoes, olives in brine. 
• Sauces such as soy, oyster, ketchup and ready spice mixes/seasonings – if using, add in smaller amounts. 
• Salted crisps and nuts. Try unsalted varieties.

Useful websites 

Action on salt: 
Action on Salt - Action on Salt

British Heart Foundation:
Salt - how much is too much? - BHF

The Eatwell Guide:
The Eatwell Guide - NHS (www.nhs.uk)

A with more information about salt:
What is salt? (youtube.com)

Useful apps

Apps you can use to scan your food and look for lower slat alternatives.

FoodSwitch
FoodSwitch UK

Better Health
Healthier Families - Home - NHS (www.nhs.uk)