A 17-year-old girl with Klippel-Weber syndrome complicated with a pulmonary thromboembolism and RV thrombus

A 17-year-old girl with multiple areas of skin hemangiomas that had been present since birth was referred to our institution complaining of sudden onset of dyspnea. Enhanced CT demonstrated a pulmonary thromboembolism and transthoracic echocardiogram showed a thrombus-like echo in the right ventricle. CT further revealed thrombi in the inferior vena cava (IVC) and peripheral vein. The thrombi, especially those in the RV, were highly life-threatening; therefore, immediate thrombectomy was performed and an IVC filter was placed. Because no major complications occurred, the patient was discharged 34 days after admission. In such young women, carefully using anticoagulation therapy and planning pregnancy are recommended.

[Anesthetic management for a pediatric patient of Klippel-Trenaunay syndrome with giant head by hydrocephalus]

Klippel-Trenaunay syndrome (KTS) is a rare disorder associated with the triad of 1) capillary vascular malformation, 2) varicose veins and/or venous malformation, 3) and soft tissue and/or bony hypertrophy. A six-month old, 6.0-kg-weight male pediatric patient was scheduled for ventriculo-peritoneal shunt operation for hydrocephalus caused by obstructive aqueductus cerebri. At the age of three months, he was diagnosed as KTS by extensive capillary vascular malformation and soft tissue hypertrophy of the right leg. Physical examination showed prominent vascular malformation over his anterior thoracic and abdominal wall, and soft tissue hypertrophy was only on his right leg. Simultaneously, he was complicated with congenital hydrocephalus because of obstructive aqueductus cerebri. His head and skull were enlarged and his head measurement reached 55 cm (chest measurement 32 cm). Anesthetic management of KTS patients should be prepared with blood transfusion against massive hemorrhage and hypovolemic shock. Furthermore, KTS patients should be always considered to have airway difficulty due to the soft tissue hypertrophy, upper and airway hemangiomas. Therefore, we planned safer tracheal intubation following practice guidelines for management of the difficult airway.

Combined lymphangioma and hemangioma of the spleen in a patient with Klippel-Trénaunay syndrome

INTRODUCTION

Klippel-Trenaunay syndrome (KTS) is a very rare congenital anomaly of blood vessels, characterized by the following clinical triad: varicose superficial veins, port-wine stain and usually bony and soft tissue hypertophy of extremities, most often located in the lower extremities. It is often accompanied by visceral manifestations, and rarely combined with splenomegaly.

CASE OUTLINE

A 30-year-old female patient came to the Surgery Clinic because of occasional left hypochondrial pain. After she was diagnosed with KTS combined with splenomegaly, splenectomy was performed. Macroscopic and microscopic spleen examination indicated the presence of tumor of vascular origin, presenting a combination of lymphangioma and hemangioma.

CONCLUSION

Diagnosed KTS demands a thorough clinical examination of the patient because of the potential presence of visceral manifestations. When splenomegaly is present, even though being often benign, splenectomy is usually performed to alleviate accompanying symptoms which occur as a result of organ enlargement and compression, to prevent rupture and consequential bleeding when the vascular spleen tumor is large, and finally to avoid a possibility of malignant transformation.

Thrombus in transit within a patent foramen ovale: an argument for consideration of prophylactic closure?

Recurrent pulmonary embolism (PE) in prothrombotic patients with patent foramen ovale (PFO) is not considered a setting for elective PFO closure. We describe a 35-year-old woman with known PFO, recurrent PE on warfarin, and Klippel-Trenaunay syndrome-a condition with predisposition for thromboembolism-who suffered concurrent saddle PE and devastating stroke with further impending paradoxical embolus across the PFO. Optimal management in patients with biatrial thromboembolus caught in transit across PFO is challenging. Patients with recurrent PE, prothrombotic states, and PFO should be considered for PFO closure. Prompt diagnosis of impending paradoxical embolus with echocardiography and consideration of surgical removal and PFO closure are critical.

[A case of Klippel-Trenaunay-Weber syndrome associated with progressive pulmonary hypertension]

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare congenital disorder characterized by varicose veins, cutaneous hemangiomas, hypertrophy of soft tissue and bone and arteriovenous malformations. We present a case of a 43-year-old man with KTWS. He experienced progressive pulmonary hypertension due to recurrent pulmonary embolism, which developed despite adequate anticoagulation. This case report suggests that patients with KTWS need more aggressive management and treatment of their thromboembolitic state and pulmonary hypertension.

[A boy with an abnormal right part of his body]

We were consulted with pictures of a 10-year-old Ukrainian boy with red maculae over a large part of his body and hypertrophy and varicose veins of the right arm and leg due to Klippel-Trenaunay syndrome.

Paradoxical brain embolism with Klippel-Trenaunay syndrome

Cerebrovascular diseases in patients with Klippel-Trenaunay Syndrome (KTS) are uncommon, and the mechanism of stroke has remained elusive. We describe a patient with KTS who experienced a transient ischemic attack (TIA). Contrast-transcranial Doppler with the Valsalva maneuver revealed a right-to-left shunt and contrast-transesophageal echocardiography confirmed patent foramen ovale. Ultrasonography revealed dilated superficial and deep veins in the lower extremities; the D-dimer level was high and indicated hypercoagulability. Therefore, the mechanism of TIA was diagnosed as paradoxical embolism. To the best of our knowledge, this is the first case report of paradoxical embolism in a patient with KTS.

[Some reflections on the Klippel Trenaunay syndrome: A single entity or an association of vascular malformations]

The author started in the year 2000, in the St Marta Hospital, a consultation for congenital vascular malformations, that was extrapolated to the Pulido Valente Hospital - CHLN where he continues to see multiple patients with this type of pathology, mainly located to the extremities.The Klippel Trenaunay syndrome, which was described as a set of anomalies constituted by the presence of a cutaneous angiomatous malformation ( port wine stain ), varicose veins and gigantism of the limbs, is undoubtedly the most common malformations that he is asked to treat. So he thought that it would be interesting to undertake an actual review of this pathology.After analyzing the various components in question he concludes that the condition is undoubtedly a set of malformations ranging from a cutaneous component, to the venous and lymphatic malformations and clear the osseous component, that causes the bone dysmorphic appearance, and that is essential a multidisciplinary approach to achieve a final satisfactory therapeutic result.

Tuberous sclerosis complex (TSC) and Klippel-Trenaunay-Weber (KTW) syndromes association of two complete phakomatoses in a single individual

Tuberous sclerosis or tuberous sclerosis complex (TSC) and Klippel-Trenaunay-Weber (KTW) syndromes are phakomatoses which are believed to be inherited separately were associated in a 21 years old female, with no family history of similar illness presented with facial rash of reddish spots or bumps, facial angiofibroma (adenoma cebaceum), which appeared on the nose and cheeks in a butterfly distribution, and sub ependymal calcific nodules on brain CT, and multiple liver, pancreas hamartomas and multiple angiomyolipomas and cysts of both kidney on ultrasound, which is consistent with a sporadic TSC, in addition, the diagnostic triad of KTW involved the left upper limb : cutaneous naevi a vascular anomaly, soft tissue and osteohypertrophy. This is the second reported association of the fully developed symptomatology of TSC and KTW in one person in Ethiopian setting.

Keloid formation occurring in the distribution of a congenital vascular malformation

A 35-year-old African American man presented with complaints of malodorous drainage from hypertrophic lesions on his occipital scalp (Figure 1, inset). The patient had no family history of keloid formation and no other keloids on his body. The hypertrophic mass on his scalp had been present for 10 years and had not been a result of any type of mechanical, surgical, or laser treatment. It corresponded to the distribution of a large vascular malformation over the occiput (Figure 1). The vascular malformation extended from the occipital scalp to the right parietal scalp, the right side of the face, neck, upper chest, and right arm, with varicosities and hypertrophy of the right upper extremity (Figure 2). The vascular malformation over the right parietal scalp and ear was characterized by bleb formation and hypertrophy of the right ear. The patient reported that no manipulation, including laser treatment, of the vascular malformation had been previously performed. He did state that a previous dermatologist had attempted serial surgical excision of the cerebriform nodules but retired during the course of treatment. He stated that the appearance of his keloid formation and port-wine stain had not changed during the past 10 years. A previous biopsy of a hypertrophic lesion showed histologic findings consistent with folliculitis keloidalis nuchae. Cephalexin 500 mg 4 times daily for 14 days was prescribed for the purulent drainage. A Doppler ultrasound was ordered of the right upper extremity to evaluate for an arteriovenous malformation and showed no evidence of venous thrombosis or arteriovenous malformation. On a second visit 2 weeks later, the hypertrophic lesions continued to show drainage. Clindamycin gel to be applied twice daily to the scalp was added. The patient also had magnetic resonance imaging with and without gadolinium contrast (Figure 3) ordered, which showed a large hypertrophic giant scalp keloid overlying the occipital and suboccipital region measuring 12x 19 cm. There was soft tissue thickening involving the right external ear, extending inferior to the right ear, overlying an intact parotid gland. There was no evidence of muscular or skull invasion.

[Klippel-Trenaunay syndrome and pregnancy. Case report]

The Klippel-Trenaunay syndrome is a rare congenital disorder consisting of: cutaneous vascular nevi, varicose veins or venous malformations and hypertrophy of soft tissue and bone, affecting one or more limbs. The morbidity of the disease is associated with vascular anomalies. Pregnancy is discouraged because this rare disease puts a pregnant woman in an increased obstetric risk, due to pregnancy can exacerbate complications. The pregnancy has been reported rarely in patients with Klippel-Trenaunay syndrome, although the incidence is unknown. Until 2006 there have been only 17 reported cases of pregnancy in patients with Klippel-Trenaunay syndrome in the literature in English. We report the case of the second pregnancy of 22 years old woman with this disease.

Peripartum cardiomyopathy and Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder of unknown etiology characterized by venous malformations or varicose veins, cutaneous capillary malformation and hypertrophy of soft tissues with limb (usually asymmetric lower extremity) involvement. Peripartum cardiomyopathy (PPCM) is characterized by rapid onset heart failure during the final month of pregnancy or within five months of delivery, in the absence of identifiable risk factors or previous heart disease. The aim of this study was to illustrate the correlation between the KTS and the onset of PPCM in women with twin pregnancies. Our case is a 35-year-old woman, gravida II para I, with KTS, twin pregnancy and PPCM. We can assume that, as the heart of a women with KTS usually works with a low preload reserve due to the widespread venous varicosities, if a significant increase in preload occurs, it may lead to the onset of cardiac dilatation and thus PPCM.

Efficacy and Safety of Microfoam Sclerotherapy in a Patient With Klippel-Trenaunay Syndrome and a Patent Foramen Ovale

BACKGROUND

Sclerotherapy with polidocanol microfoam injection under duplex guidance is a new treatment for venous malformations associated with Klippel-Trenaunay syndrome. Multidetector-row computed tomography (MDCT) venography is extremely helpful in the assessment of disease extension and the planning of therapy. Observation In this particular case, MDCT venography demonstrated the origin, course, and relationship to adjacent anatomical structures of aberrant vessels that configure the superficial venous system with an anatomically normal and patent deep venous system. At the end of the treatment, which consisted of 8 sessions of microfoam sclerotherapy within 12 months, a considerable reduction in the number and size of the percutaneously treated aberrant veins was observed. The obvious clinical improvement was objectively demonstrated with MDCT venography, which showed clear reduction in the number and size of treated veins. Further clinical investigation performed because of isolated migraine episodes related to the sclerotherapy session revealed that the patient had a patent foramen ovale. A transcranial Doppler examination during the procedure showed middle cerebral artery bubbles, which indicated right-to-left shunt. No cerebral damage was observed in a subsequent diffusion-weighted magnetic resonance examination.

CONCLUSIONS

Microfoam sclerotherapy is an effective treatment option in patients with Klippel-Trenaunay syndrome. MDCT venography allows diagnosis of the disease, planning of therapy, and assessment of response to treatment. Although foam-induced microembolism is a common phenomenon during sclerotherapy, in this report we demonstrate that polidocanol microfoam prepared with a low-nitrogen gas mixture is safe in a patient with a patent foramen ovale.

Delayed diagnosis of iliac vein thrombus in a sexually-active adolescent with Klippel-Trénaunay syndrome

BACKGROUND

Although iliac vein thrombus is uncommon in adolescents, it can present with pelvic inflammatory disease (PID) symptoms.

CASE

A 19-year-old sexually active female with Klippel-Trénaunay syndrome (KTS) presented with fever, abdominal and lower extremity pain. Physical findings included cervical motion tenderness and left lower extremity swelling and erythema. The patient was admitted for PID and cellulitis. Despite antimicrobial treatment her pain continued. Neisseriae gonorrhea and Chlamydia trachomatis cultures were negative. Abdominal and pelvic computed tomography scans revealed a left internal iliac vein thrombus. Anticoagulation therapy was initiated; her pain improved. On hospital day 7 she developed pulmonary emboli.

SUMMARY AND CONCLUSION

In sexually active adolescents with known risk factors for thromboembolism such as KTS, symptoms and signs considered characteristic for PID can be present in association with an iliac vein thrombus.

Gigantism of the lower limb in Klippel-Trenaunay syndrome: anatomy of the lateral marginal vein

The Klippel-Trenaunay syndrome is a combination of venous and capillary malformations associated with soft tissue and/or bony limb hypertrophy, with or without lymphatic malformations. Although persistent foetal veins are rare, the persistence of the lateral marginal vein is a common association in this syndrome. It results in venous hypertension, which gives rise to venous varicosities, which are commonly seen in this syndrome. This is a case report of a 28-year-old man with Klippel-Trenaunay syndrome, with persistence of the lateral marginal vein, affecting his right lower limb. He was treated with an above-knee amputation. The amputated limb was dissected to demonstrate the anatomy of the lateral marginal vein. To the best of the authors' knowledge, the gross anatomy of the lateral marginal vein has not been previously reported.

[Obstetric management of Klippel-Trenaunay syndrome. A case report]

A rare case of pregnancy in a patient with Klippel-Trenaunay-Weber syndrome is described. The arterio-venous anomalies in this patient originally occurred in her left leg. Her pregnancy was uneventful. A Cesarean section was performed at term. There were no signs of intravascular coagulation or cardiac decompensation. Prophylactic anticoagulant treatment was given during the 3rd trimester and into the early puerperium The clinical course and the risks of a pregnancy with this condition are discussed.

CONCLUSION

Klippel-Trenaunay syndrome was once thought to be a contraindication to pregnancy. With careful management, successful pregnancies can be achieved.

Symptomatic foraminal extradural meningeal cyst

The authors described the case of a 39-year-old man with Klippel-Trénaunay syndrome, who had an extradural meningeal cyst expanding into intervertebral foramen of lumbar 2 and 3 vertebrae. The patient suffered from low back pain radiating to the left lower extremity. Magnetic resonance imaging revealed a huge extradural meningeal cyst growing through intervertebral foramen far laterally. A widened neural foramen of L2 and L3 vertebrae was observed on his plain radiography. The cyst was totally excised after tying the ostium connecting the subarachnoid space of the dural sac. This case supports the congenital theory in the pathogenesis of spinal cysts because the Klippel-Trénaunay syndrome is a congenital disorder including a mesodermal abnormality which may be the causative factor for a congenital defect in dura.

Vascular malformations as underlying cause of chronic thromboembolism and pulmonary hypertension

We report four patients with chronic thromboembolic pulmonary hypertension (CTEPH) presumably due to recurrent pulmonary embolism from low-flow vascular malformations, and give a review of the literature. Venous malformations, such as those observed in Klippel- Trenaunay syndrome (KTS) can be associated with hypercoagulability, thrombosis and recurrent pulmonary embolism and ultimately CTEPH. Since many physicians appear unfamiliar with these potential complications, patients may experience a delayed diagnosis of this progressive and potentially life-threatening CTEPH.

Maldevelopments of the vascular system: clinical conundrums

Defects in angiogenesis occurring in utero produce a broad spectrum of clinical abnormalities. Some regress in infancy, some persist and may be allied with abnormalities of other structures. The possible interrelationships between abnormalities of the arterial, venous and lymphatic systems and skeletal development are explored in this paper.