Chronic venous insufficiency is commonly treated with non-tumescent non-thermal methods, among which cyanoacrylate-based vein closure is recognized for its high occlusion rate and patient satisfaction [1]. However, allergic reactions, occurring at a relatively high rate, pose a significant challenge for both patients and clinicians [2]. The primary concern with these reactions lies in their unpredictable onset and severity [3]. Fortunately, most cases involve mild allergic responses. Nevertheless, rare cases of recurrent and systemic allergic reactions can occur, as illustrated in the following patient case.

A 31-year-old female patient presented with symptoms of leg swelling, heaviness, and cramps (CEAP 3). A Doppler ultrasound revealed significant reflux in the great saphenous vein, for which cyanoacrylate vein closure was performed. The procedure was uneventful, and the patient was discharged the same day.

On postoperative day 8, the patient developed redness rash and itching sense at the surgical site, with a rash extending toward the abdomen. The symptoms improved with NSAIDs, antihistamines, and steroids, and the reaction was initially interpreted as a localized allergic response to cyanoacrylate. However, on postoperative day 15, although symptoms at the surgical site improved, a rash appeared on the abdomen, progressed to the face and arms. The patient also experienced respiratory distress, prompting an emergency department visit where supportive treatment was administered. Although symptoms temporarily improved, the patient experienced recurrent allergic reactions on postoperative days 48, 112, and 223. While less severe with each recurrence, the reactions persisted (Fig. 1).

Figure 1. (A) Abdominal rash. (B) Rash spreading on the arm. (C) Urticaria on the back. (D) Localized reaction at the surgical site.

Allergic reactions to cyanoacrylate are generally type IV hypersensitivity reactions, characterized by delayed localized responses. Systemic reactions are extremely rare. Reports of cases necessitating cyanoacrylate removal typically involve severe, repetitive local reactions directly attributable to the substance [4]. However, unlike cyanoacrylate, these materials are relatively easier to remove. However, in this case, the patient exhibited recurrent systemic allergic reactions, including rash, itching, and respiratory symptoms, following the procedure. Several studies have reported cases of systemic allergies caused by medical devices such as implanted metals or fillers in the human body [5,6].

The patient’s medical history included food allergies but no regular medication use. Her symptoms clearly escalated postoperatively, with persistent discomfort impacting her quality of life. Several treatment approaches may be considered:

1. Conservative management

Continue the current regimen of medications (NSAIDs, antihistamines, and steroids) during symptomatic episodes. However, the duration of such treatment remains uncertain.

2. Removal of cyanoacrylate

Given the recurring and worsening nature of symptoms, removing the cyanoacrylate may be an option. Yet, there is uncertainty about whether cyanoacrylate is the definitive causative factor.

3. Immunotherapy

As cyanoacrylate within the vein might act as a neoantigen, triggering an immune response, targeted immunotherapy could be explored to address the underlying mechanism.

The patient’s preferences and concerns should be carefully considered when determining the next steps. While such adverse effects are rare, clinicians bear the responsibility of addressing them effectively. Preoperative screening for potential allergic triggers, such as medication and food allergies, should be conducted more rigorously to minimize risks in similar cases.

The authors declare no conflicts of interest.

This report was presented under the title of recurrent systemic urticaria following cyanoacrylate closure for the treatment of incompetent saphenous veins, at the 47th annual academic meeting of The Korean Society for Phlebology.