New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation

Arteriovenous malformations: ethanolamine oleate sclerotherapy

Peripheral vascular malformations are now described according to some accepted guidelines, and the principle of proper treatment (nodus ablation) is becoming clear. An appropriate classification schema for vascular anomalies and definite indications for treatment are important to successful treatment overall. Non-invasive imaging (US, CT, and MRI) in association with clinical findings is critical in establishing the diagnosis, evaluating the extent of the malformation, and planning appropriate treatment. Direct nidus phlebography is useful not only in making a correct diagnosis but also in treating the lesion by sclerotherapy. When a patient suffers clinical complications, the nidus sclerotherapy becomes mandatory. If the vascular malformation remains bloodstream to a drainage vein during nidus opacification, flow control is necessary to achieve complete nidus ablation. A multidisciplinary approach is needed in the treatment of a high-flow lesion. A dedicated team approach is necessary for appropriate management in most cases.

Haemodynamic and Clinical Assessment of Lateral Marginal Vein Excision in Patients with a Predominantly Venous Malformation of the Lower Extremity

OBJECTIVE

The purpose of the present study was to determine the effects of the surgical excision of lateral marginal veins (LMVs) in patients with a venous malformation (VM) affecting the lower extremity.

METHODS

Preoperative and postoperative air plethysmography (APG), CEAP classification C scores, and venous clinical severity scores (VCSS) of the 25 VM patients who underwent LMV excision were compared.

RESULTS

After LMV excision, venous haemodynamic parameters revealed significantly increased ejection fraction (EF, 33.2 S.D.18.5% vs. 39.7 S.D.21.2%, P=.020), and reduced venous volume (VV, 235.0 S.D.141.8 ml vs. 198.0 S.D.114.1 ml, P=.016) and residual venous fraction (RVF, 62.4 S.D. 26.6% vs. 56.9 S.D. 25.3%, P=.046). Clinical assessments of affected limbs revealed significantly improved mean CEAP C scores and VCSS (preoperative score, 4.4 S.D.1.7 vs. postoperative score 2.4 S.D.1.7, P=.026) after LMV excision versus preoperative data.

CONCLUSION

Haemodynamic and clinical improvements were observed in patients with lower extremity VM after LMV excision.

Classification, diagnosis, and interventional radiologic management of vascular malformations

Vascular anomalies are comprised of either hemangiomas or vascular malformations.Low-flow vascular malformations can be divided into capillary, venous, and lymphatic types and are usually present at birth, undergo pari passu growth, and produce symptoms related to mass effect or stasis. High-flow malformations are comprised pre-dominantly of arteriovenous malformations that follow a more aggressive clinical course of hyperemia, adjacent mass effect, steal phenomenon, tissue destruction, and ultimately high output failure. Ultrasound, CT, nuclear medicine, angiography, and particularly MRI have greatly enhanced diagnostic accuracy and provide detailed information for percutaneous and surgical treatment planning and an objective means of following therapeutic efficacy. Interventional radiologic percutaneous sclerotherapy for low-flow lesions and embolosclerotherapy for high-flow lesions with or without adjunctive surgical intervention have become the mainstay of therapy.

Peripheral vascular malformations: imaging, treatment approaches, and therapeutic issues

Peripheral vascular malformations are now described according to some accepted guidelines, and the principle of proper treatment (nidus ablation) is becoming clear. An appropriate classification scheme for vascular anomalies and definite indications for treatment are important to successful treatment overall. The findings from noninvasive imaging (ie, Doppler ultrasonography, computed tomography, or magnetic resonance imaging) in association with clinical findings are critical in establishing the diagnosis, evaluating the extent of the malformation, and planning appropriate treatment. Direct opacification of the nidus is useful, not only in making a correct diagnosis, but also in treating the lesion with sclerotherapy. In most cases, conservative treatment is recommended, but when a patient suffers clinical complications (eg, ulceration, pain, hemorrhage, cardiac failure, or unacceptable cosmetic consequences), the nidus sclerotherapy becomes mandatory. If the vascular malformation has blood outflow to a drainage vein during nidus opacification, flow control (with balloon occlusion, tourniquet, or embolization) is necessary to achieve sclerosant stasis within the nidus. Embolotherapy (with a coil, n-butyl cyanoacrylate, or small particles) should be used for subsequent multifaceted palliative therapy. A multi-disciplinary approach is needed in the treatment of a high-flow lesion, and a dedicated team approach is necessary for appropriate management in most cases.

Treatment for extracranial arteriovenous malformations of the head and neck

CONCLUSIONS

For extracranial arteriovenous malformations of the head and neck (HNAVMs), in which the nidus was accessible via the percutaneous route, ethanol sclerotherapy was a feasible and safe first-line treatment, although successful outcomes were obtained for only about half of the subjects. For other HNAVMs, surgical excision with embolization may be the best choice of treatment.

OBJECTIVE

To suggest a treatment protocol for patients with HNAVMs by comparing the treatment outcomes and complications of ethanol sclerotherapy with those of surgical excision combined with embolization.

MATERIAL AND METHODS

Twenty patients who had been diagnosed with HNAVM and treated between 1995 and 2002 were retrospectively reviewed. Ethanol sclerotherapy, surgical excision and embolization were used as treatments, either alone or in various combinations. The treatment outcomes and complications with the different modalities were analyzed.

RESULTS

Ethanol sclerotherapy was used for 12 cases, with a success rate of 50.0% and a permanent complication rate of 8.3%. Surgical excision combined with embolization was used for 13 patients. Although all patients achieved successful resolution of their HNAVM after surgical excision, 15.4% suffered from permanent complications. In total, 16/20 patients (80.0%) eventually achieved a > or = 75% reduction in the size of their lesions.

Dynamic MRI for Distinguishing High-Flow from Low-Flow Peripheral Vascular Malformations

OBJECTIVE

The purpose of our study was to assess the usefulness of dynamic MRI in distinguishing high-flow vascular malformations from low-flow vascular malformations, which do not need angiography for treatment.

SUBJECTS AND METHODS

Between September 2001 and January 2003, 16 patients who underwent conventional and dynamic MRI had peripheral vascular malformations (six high- and 10 low-flow). The temporal resolution of dynamic MRI was 5 sec. Time intervals between beginning of enhancement of an arterial branch in the vicinity of a lesion in the same slice and the onset of enhancement in the lesion were calculated. We defined these time intervals as "artery-lesion enhancement time." Time intervals between the onset of enhancement in the lesion and the time of the maximal percentage of enhancement above baseline of the lesion within 120 sec were measured. We defined these time intervals as "contrast rise time" of the lesion. Diagnosis of the peripheral vascular malformations was based on angiographic or venographic findings.

RESULTS

The mean artery-lesion enhancement time of the high-flow vascular malformations (3.3 sec [range, 0-5 sec]) was significantly shorter than that of the low-flow vascular malformations (8.8 sec [range, 0-20 sec]) (Mann-Whitney test, p < 0.05). The mean maximal lesion enhancement time of the high-flow vascular malformations (5.8 sec [range, 5-10 sec]) was significantly shorter than that of the low-flow vascular malformations (88.4 sec [range, 50-100 sec]) (Mann-Whitney test, p < 0.01).

CONCLUSION

Dynamic MRI is useful for distinguishing high-flow from low-flow vascular malformations, especially when the contrast rise time of the lesion is measured.

Direct percutaneous ethanol instillation for treatment of venous malformation in the face and neck

Venous malformations of the face and neck involve multiple anatomical spaces and encase critical neuromuscular structures, making surgical treatment difficult; high recurrence rates and high morbidity are well documented. Various methods of treatment of uncertain value and risk of complications have been advocated. We present our experience in treating five patients with venous malformation in the face and neck by using direct percutaneous ethanol sclerotherapy. Four patients had large lesions (> or = 3 cm; one patient had two large lesions in the low eyelid), and the other had a mid-sized lesion (1.5-3 cm). Under general or local anaesthesia, one-third to one-quarter cavity volume of ethanol was injected percutaneously, directly into the malformation with under fluoroscopy [de Lorimier AA. Sclerotherapy for venous malformations. J Pediatr Surg 1995;30:188-93; Johnson PL, Eckard DA, Brecheisen MA, Girod DA, Tsue TT. Percutaneous ethanol sclerotherapy of venous malformations of the tongue. Am J Neuroradiol 2002;23:779-82; Pappas DC Jr, Persky MS, Berenstein A. Evaluation and treatment of head and neck venous vascular malformations. Ear Nose Throat J 1998;77:914-22; Lee CH, Chen SG. Direct percutaneous ethanol sclerotherapy for treatment of a recurrent venous malformation in the periorbital region. ANZ J Surg. 2004;74(12):1126-7.]. Four patients required two injections. All patients had remission and alleviation of their symptoms, with no major complications. Direct percutaneous injection of absolute ethanol provides a simple and reliable alternative treatment for venous malformation in the face and neck.

New Approaches to the Treatment of Congenital Vascular Malformations (CVMs)—A Single Centre Experience

OBJECTIVE

A retrospective review of the results of management of congenital vascular malformation (CVM) patients was made to assess the efficacy of newly introduced approaches.

METHODS

CVMs were categorised according to the Hamburg classification on the basis of minimally invasive tests. Invasive studies such as angiography are used to provide a road map for treatment. A new multidisciplinary approach was adopted, which accepts the integration of embolisation and sclerotherapy with traditional surgical therapy. Embolo-sclerotherapy was used as an independent therapy and as an adjunctive therapy to surgery.

RESULTS

Ninety-nine out of a total of 294 venous malformation patients underwent ethanol sclerotherapy with an immediate success rate of 98.8%, requiring 419 sessions of treatment. Interim results were excellent with no evidence of recurrence (mean follow-up 18.2 months). Most of the 25 patients treated surgically received pre-operative embolo-sclerotherapy, each with excellent interim results and minimum morbidity (mean follow-up 21.2 months). Forty-eight patients among 76 arteriovenous malformation patients underwent embolo-sclerotherapy independently (32/48) or adjunctively (16/48). Independent therapy on 32 produced excellent interim results (25/32) requiring a total of 171 sessions (mean follow-up 19.2 months). Eighty-nine extratruncal (ET) forms of lymphatic malformations received multiple sessions of sclerotherapy with OK-432 (108/120 sessions) or ethanol (12/20 sessions). OK-432 was used in 51 paediatric patients with the ET form and produced an excellent response in cystic type lesions (40/45) requiring 61 sessions with no evidence of recurrence (mean follow-up 24.2 months), whereas a mixed result was obtained in the cavernous type (3/6). OK-432 sclerotherapy was used as a pre-operative adjunctive therapy in 7 patients requiring 21 sessions with 17 cavernous type of the ET form, and produced good to excellent results after surgical excision of 14 lesions.

CONCLUSION

New approaches to the treatment of CVMs based on a multidisciplinary approach can improve results by fully combined surgical treatment with embolo-sclerotherapy.

Imaging of head and neck venous malformations

Venous malformations (VMs) are non proliferative lesions that consist of dysplastic venous channels. The aim of imaging is to characterise the lesion and define its anatomic extent. We will describe the plain film, ultrasound (US) (including colour and duplex Doppler), computed tomography (CT), magnetic resonance imaging (MRI), conventional angiographic and direct phlebographic appearances of venous malformations. They will be illustrated at a number of head and neck locations, including orbit, oral cavity, superficial and deep facial space, supraglottic and intramuscular. An understanding of the classification of such vascular anomalies is required to define the correct therapeutic procedure to employ. Image-guided sclerotherapy alone or in combination with surgery is now the first line treatment option in many cases of head and neck venous malformations, so the radiologist is now an integral part of the multidisciplinary management team.

Bone lymphangiomatosis: treatment with percutaneous cementoplasty

STUDY DESIGN

Case report, minimally invasive technique.

OBJECTIVES

Disseminated lymphangiomatosis is a rare disorder that can produce clinical manifestation secondary to soft tissue, visceral and bone involvement. The overall prognosis of this disorder is usually poor, and the current treatment options for its sequelae are limited and only palliative. In this report, we present the use of cementoplasty in the percutaneous treatment of a sacral lymphangiomatous bone lesion producing severe pain.

SUMMARY OF BACKGROUND DATA

Disseminated lymphangiomatosis is a rare disorder that can produce clinical manifestation secondary to soft tissue, visceral, and bone involvement. Major morbidity related to skeletal involvement requiring surgical intervention is less common than that related to visceral involvement, but it has been reported in a few case reports to palliate neurologic sequelae secondary to vertebral involvement. We present case of osteoplasty used to treat a painful osteolytic sacral lesion in a patient with diffuse lymphangiomatosis. Computed tomography guided osteoplasty injecting acrylic bone cement into the lesion resulted in almost immediate reduction in pain.

METHODS

The technique and results of minimally invasive percutaneous computed tomography-guided cementoplasty of a painful osteolytic sacral lesion resulting from chylous reflux in a patient with lymphangiomatosis is presented.

RESULTS

Computed tomography was used to accurately position a 13-gauge needle into a dominant sacral osteolytic lesion. The injection of bone cement into the sacral lesion was then monitored by intermittent CT imaging. The patient reported substantial pain relief within several hours of the procedure.

CONCLUSION

The case presented demonstrates the feasibility and efficacy of computed tomography-guided cementoplasty used to palliate unusual causes of benign osteolytic bone lesions. These procedures can be performed as outpatients with minimal recovery.

Radiofrequency Ablation for Treatment of Symptomatic Low-flow Vascular Malformations after Previous Unsuccessful Therapy

Three patients with low-flow soft-tissue vascular malformations were treated with radiofrequency (RF) ablation. Other treatment options had proven unsuccessful. After RF ablation treatment, two patients were free of symptoms and one reported decreased symptoms followed by a return of symptoms within 1 year. No procedure-related complications occurred. It is suggested that RF ablation may be offered as an alternative treatment option for symptomatic vascular malformations when others have failed or are not possible.

Ethanol sclerotherapy of peripheral venous malformations

BACKGROUND

Venous malformations are congenital lesions that can cause pain, decreased range of movement, compression on adjacent structures, bleeding, consumptive coagulopathy and cosmetic deformity. Sclerotherapy alone or combined with surgical excision is the accepted treatment in symptomatic malformations after failed treatment attempts with tailored compression garments.

OBJECTIVES

To report our experience with percutaneous sclerotherapy of peripheral venous malformations with ethanol 96%.

PATIENTS AND METHODS

41 sclerotherapy sessions were performed on 21 patients, aged 4-46 years, 15 females and 6 males. Fourteen patients were treated for painful extremity lesions, while five others with face and neck lesions and two with giant chest malformations had treatment for esthetic reasons. All patients had a pre-procedure magnetic resonance imaging (MRI) study. In all patients, 96% ethanol was used as the sclerosant by direct injection using general anesthesia. A minimum of 1-year clinical follow-up was performed. Follow-up imaging studies were performed if clinically indicated.

RESULTS

17 patients showed complete or partial symptomatic improvement after one to nine therapeutic sessions. Four patients with lower extremity lesions continue to suffer from pain and they are considered as a treatment failure. Complications were encountered in five patients, including acute pulmonary hypertension with cardiovascular collapse, pulmonary embolus, skin ulcers (two) and skin blisters. All patients fully recovered.

CONCLUSION

Sclerotherapy with 96% ethanol for venous malformations was found to be effective for symptomatic improvement, but serious complications can occur.

Vascular low-flow malformations in children: current concepts for classification, diagnosis and therapy

Congenital vascular malformations (CVM) are made of dysplastic vessels with no cellular proliferation. Low- or slow-flow malformations (LFM) consist predominantly of venous and/or lymphatic vessels. Correct terminology is necessary for differentiating vascular malformations from tumours such as haemangiomas, in order to prevent ineffective or even adverse therapy. The role of the radiologist in the management of patients is two-fold: making the diagnosis with the use of ultrasound and magnetic resonance imaging, and performing sclerotherapy, which is the treatment of choice. Prior to sclerotherapy, percutaneous phlebography is necessary to visualize the dynamic situation inside the lesion and the flow into the adjacent vascular system. The double-needle technique is a useful therapy option reducing the risk of embolisation of the sclerosing agent. Large lesions might need subsequent surgical treatment. A multidisciplinary approach is substantial for optimal patient management.

A new sclerosing agent in the treatment of venous malformations. Study on 23 cases

SUMMARY

Absolute ethanol is the most effective agent in the treatment of venous malformation (VM) although it is quite risky to use because of the danger of diffusion beyond the target. To reduce this risk, we have developed an alcoholic sclerosing solution that is less diffusible. The viscosity of absolute ethanol was enhanced with monographic ethyl-cellulose at a concentration of 5.88% ie 0.75 g in 15 ml of absolute ethanol 95%. 23 patients with VM located on the buttock (1), hand (2), leg (1) and face (19) were treated. A mean volume of 1.99 ml of the solution was injected directly into the VM. Each patient had an average of 2.8 procedures. Sixteen patients were done under general anaesthesia and seven with local anaesthesia. Evaluation was performed by the patient, the dermatologist of the treating multidisciplinary team and a dermatological group not involved in the treatment of the patients. Patients were evaluated after a mean delay of 24.52 months. Evaluation of the cosmetic result was made with a five point scale and the global result with a three point scale. VM pain was evaluated by the patients with a Visual Analogue Scale. The aesthetic results were graded as satisfactory (> 3) for the patient and the dermatologist of the multidisciplinary team. However the results were not as good with the independent dermatological group evaluation. The pain was significantly less important after the treatment (p << 0.001). Among the 23 patients, the local adverse events were nine necrosis with or without ethylcellulose fistula followed by only two surgical procedures. There were no systemic adverse events. Sclerotherapy of VM is usually performed with absolute ethanol or ethibloc. The main advantage of our sclerosing mixture is that it expands like a balloon when injected slowly in a aqueous media. Because of the important increase in viscosity the volume of injected solution is much lower than ethanol alone and the risk of systemic reactions is lower. Contrary to ethibloc, post-sclerosing surgery is not necessary because sub-cutaneous ethylcellulose disappears secondarily.

Critical Issues in Management of Congenital Vascular Malformation

Congenital vascular malformation (CVM) has long been a challenging problem. Recently, a new classification of CVMs was launched, opening up a new era. This improved definition provides critical information on CVM etioanatomopathophysiology. Advanced diagnostic technology has also provided more accurate and safer diagnosis. Finally a new, improved method of managing CVMs based on a new, multidisciplinary approach has emerged. In this study, various noninvasive diagnostic tests were adopted for contemporary diagnosis, and invasive studies were reserved for use as a road map for treatment. A new treatment strategy evolved, following proper identification of absolute and relative indications for treatment, which integrates surgical therapy and embolosclerotherapy. Three hundred and sixty-two patients selected for treatment, among a total of 1007 patients with various indications, were retrospectively reviewed. Various embolosclerotherapy techniques were performed on 333 patients, including 640 sessions of ethanol-based therapy. The immediate success rate was excellent (96.2%) but was accompanied by various complications mostly of a minor nature during 212 sessions (22%). The interim results were also excellent, with no evidence of recurrence. A total of 102 patients underwent 128 surgical procedures, consisting of a variety of different therapies, either independently (29/102) or in conjunction with preoperative embolosclerotherapy (73/102). Most of the interim results were excellent (111/128). The use of a complex therapy regimen through a multidisciplinary approach leads to a more manageable and satisfactory outcome.

The new role of magnetic resonance imaging in the contemporary diagnosis of venous malformation: can it replace angiography?1 1No competing interests declared

BACKGROUND

Magnetic resonance imaging (MRI) is well accepted for the contemporary diagnosis of venous malformation (VM), providing hemodynamic and anatomic information on the lesion, including its relationship with surrounding tissues and organs.

STUDY DESIGN

A total of 196 clinically suspected VM patients were reviewed retrospectively to assess the accuracy and reliability of MRI for the diagnosis of VM. Initial workup included MRI, duplex ultrasonography, and whole-body blood pool scintigraphy, along with additional transarterial lung perfusion scintigraphy and lymphoscintigraphic assessment when indicated. Phlebography or arteriography, or both, were generally reserved as a road map for the treatment. A total of 294 MRI findings for 196 patients were also compared with the matching duplex ultrasonography findings available for 178 patients and matching whole-body blood pool scintigraphy findings for 136 patients. The phlebographic findings available for 87 patients were also compared.

RESULTS

Among the 196 patients with clinically suspected VM, 174 were confirmed as having VM by MRI with true-positive findings and 2 as false-positive findings by MRI (sensitivity, 98.9%; positive predictive value, 98.9%). MRI ruled out VM for 18 patients with true-negative findings, though 2 were false-negative (specificity, 90%; negative predictive value, 90.0%). Two positive and two false-negative findings of VM, made by MRI, were subsequently confirmed by angiography. Among the 87 patients for whom phlebographic findings were available, 73 were confirmed as true-positive diagnoses of VM, 1 as false-positive, 11 as true-negative, and 2 as false-negative (sensitivity, 97.3%; specificity, 91.7%; positive predictive value, 98.7%; negative predictive value, 84.6%).

CONCLUSIONS

MRI is likely to modify the traditional role of angiography for the management of VM and become a new standard, at least for diagnosis. MRI also is an excellent parameter in the assessment of treatment results.

Management of arteriovenous malformations: a multidisciplinary approach

BACKGROUND

Management of arteriovenous malformations (AVMs) remains challenging because of their unpredictable behavior and high recurrence rate. A multidisciplinary approach based on a new classification scheme and improved diagnostic techniques may improve their management. The purpose of this study was to review our experience with combined embolotherapy, sclerotherapy (embolo/sclerotherapy), and surgical procedures to manage AVMs.

METHODS

A total of 797 patients with congenital vascular malformations (January 1995 through December 2001) was investigated with noninvasive studies. Once an AVM was diagnosed, all underwent angiographic confirmation as a roadmap for treatment. Embolo/sclerotherapy and surgical procedures were instituted by the multidisciplinary team with periodic follow-up per protocol. Seventy-six patients with AVMs were reviewed retrospectively to assess the diagnosis and management by a multidisciplinary approach.

RESULTS

Seventy-six (9.5% of all CVM) patients had AVMs, mostly infiltrating, extratruncular form (61/76). Embolo/sclerotherapy with various combinations of absolute ethanol, N-butyl cyanoacrylate (NBCA), contour particles, and coils were used in 48 patients. Sixteen patients with surgically accessible localized lesions completed preoperative embolism and sclerotherapy through 24 sessions, with subsequent surgical excision with minimal morbidity. Interim results were excellent, with no evidence of recurrence in all 16 patients with a mean follow-up of 24 months. Thirty-two patients with surgically inaccessible lesions (infiltrating) were treated with embolism and sclerotherapy alone. There were nine failures in a total of 171 sessions. Interim results with a mean of 19 months' follow-up of embolism and sclerotherapy alone were excellent in the majority (25/32) and good to fair among the rest (7/32). However, 31 complications, mostly minor (27/31), occurred in 30 sessions. Four major complications occurred, including facial nerve palsy, pulmonary embolism, deep vein thrombosis, and massive necrosis of an ear cartilage.

CONCLUSIONS

Diagnosis and management of AVMs by a multidisciplinary approach that integrates surgical therapy with embolism and sclerotherapy appears to improve the results and management with limited morbidity and no recurrence during early follow-up.

Advanced management of venous malformation with ethanol sclerotherapy: mid-term results

PURPOSE

This paper is an update of previously published data on the basis of a retrospective review of midterm results of ethanol sclerotherapy on 87 patients (January 1995 to December 2000) for assessment of its efficacy as an improved treatment method for venous malformation (VM). According to this assessment, VMs were defined with a new classification and studied with advanced diagnostic technology and an advanced care system.

METHODS

The average follow-up period was 24 months after completion of a multisession treatment (mean, 8.2 months). Classification of VM was based on a modification of the Hamburg classification. Advanced diagnostic technology, mostly noninvasive, was used on 226 of 520 patients with congenital vascular malformation registered at the Congenital Vascular Malformation Clinic at the Samsung Medical Center. Of the 226 patients with VM, 87 with infiltrating extratruncular lesions had a total of 399 sessions of sclerotherapy. Follow-up assessment with periodic clinical examinations by the multidisciplinary team was supplemented with body blood pool scans, duplex scans, and magnetic resonance imaging, according to protocol, once the multisession therapy was completed. Angiographic assessment was seldom included. The endpoint of this phase II study was 24 months.

RESULTS

Of 399 sessions, initial success was seen in 379 sessions (95.0%) and failure was seen in 20 sessions (5%). This was mostly caused by forced abandonment from technical difficulty in delivering ethanol safely to the lesion (eg, direct drainage of VM into normal deep vein system). Later results after completion of the multisession therapy with a minimum follow-up of 24 months on 71 VMs have shown no evidence of recurrence. Eighty-seven patients have shown the same results without recurrence on an average of 18.2 months of follow-up. Fifty-one minor to major complications, mostly skin damage, developed after 47 sessions among the 379 sessions (12.4% in 24/87 patients; 27.9%). However, complications resolved spontaneously or were managed successfully, except for one permanent facial nerve palsy and one peroneal nerve palsy.

CONCLUSION

Absolute ethanol sclerotherapy can deliver excellent results as an independent therapy to the infiltrating type of extratruncular form of VM, which was once taboo because of prohibitively high morbidity. Absolute ethanol may be accepted as an effective treatment method because no recurrence has been observed in the relatively long-term observation period and the morbidity has been acceptable. However, it should be reserved only for individuals and centers with expertise. The morbidity involved should be clearly understood and accepted by the patient or family, and the risk of acute and chronic complications, both major or minor, should be explained to the patient. Long-term assessment of the complication's sequelae is warranted.

Embolization of high flow arteriovenous malformations: experience with use of superabsorbent polymer microspheres

PURPOSE

To determine efficacy, safety, and requirements for adjunctive embolization or surgery in the treatment of symptomatic arteriovenous malformations (AVMs) with superabsorbent polymer microsphere (SAP-MS) particles.

MATERIALS AND METHODS

SAP-MS particles (sodium acrylate and vinyl alcohol copolymer) are nonbiodegradable spheres with a precisely calibrated diameter. SAP-MS particles swell by absorbing fluids and become soft and deformable. Twenty-five patients (16 men, nine women; mean age, 32 y; range 12-66 y) with symptomatic facial (n = 5), upper- (n = 8) and lower- (n = 12) extremity AVMs were treated primarily (n = 23) or preoperatively (n = 2) by transarterial embolization (TAE) treatment with use of SAP-MS particles. Direct puncture embolization (DPE; n = 4) and/or surgical intervention (n = 5; ie, skin graft, resection, or amputation) were required. Surgical specimens from the resected (n = 2) and the amputated (n = 2) patients were evaluated histologically. Follow-up study, including clinical findings and imaging studies, was performed at intervals ranging from 3 months to 1 year. Clinical outcome was evaluated retrospectively, depending on the subjective improvement of symptoms and signs, according to the medical records.

RESULTS

Seventy-two TAEs (range, 1-11; mean, 2.8) and 12 DPEs (range, 1-3; mean, 2.4) were performed during the mean follow-up period of 38 months (range, 7-110 mo). Twenty patients (80%) experienced symptom improvement by embolotherapy alone (n = 17) or in combination with surgery (n = 3). One lip and two finger AVMs were totally removed by surgical excision or amputation after TAE treatment. In diffuse upper- (n = 1) and lower- (n = 1) extremity AVMs, the symptoms were uncontrolled. No nerve injury or skin necrosis was observed after TAE treatment with SAP-MS particles. Mucosal necrosis was induced by DPE with ethanol in one patient. Histologically, SAP-MS particles penetrated intralesional vessels and conformed to the vessel lumen, resulting in tight vessel occlusion. Minimal perivascular reaction was observed.

CONCLUSION

SAP-MS particles were used safely in TAE treatment of AVM. TAE treatment with use of SAP-MS particles was suitable for certain symptomatic AVMs, but diffuse AVMs remain a challenge and a combination of alternative methods will be necessary for further strategy.

Duplex-guided foam sclerotherapy for the treatment of the symptomatic venous malformations of the face

BACKGROUND

New sclerosing foam is considered to have the advantage of causing more damage on the intima than liquid form. Therefore we recently applied duplex-guided foam sclerotherapy in a patient with venous malformations of the face.

METHODS

A 20-year-old man was referred to our institute for the evaluation and treatment of vascular malformations of the face. Preoperative duplex scanning and magnetic resonance imaging (MRI) revealed subcutaneous and intramuscular venous malformations. The sclerosing foam was produced by Tessari's method using 1% polidocanol, and the duplex-guided foam sclerotherapy was performed under general anesthesia. A 20-gauge plastic needle was inserted into the venous space using ultrasound guidance and a total of 5 ml of sclerosing foam was infused followed by immediate tie-over dressing.

RESULTS

The venous malformations were successfully reduced in size and postoperative MRI showed significant reduction of the venous malformations.

CONCLUSION

Although further collective study is necessary to ensure the validity of this treatment, duplex-guided foam sclerotherapy could have great promise in the treatment of symptomatic venous malformations.

Value of dynamic contrast-enhanced MR imaging in diagnosing and classifying peripheral vascular malformations

OBJECTIVE

Our purpose was to evaluate prospectively whether MR imaging, including dynamic contrast-enhanced MR imaging, could be used to categorize peripheral vascular malformations and especially to identify venous malformations that do not need angiography for treatment.

SUBJECTS AND METHODS

In this blinded prospective study, two observers independently correlated MR imaging findings of 27 patients having peripheral vascular malformations with those of diagnostic angiography and additional venography. MR diagnosis of the category, based on a combination of conventional and dynamic contrast-enhanced MR parameters, was compared with the angiographic diagnosis using gamma statistics. Sensitivity and specificity of conventional MR imaging and dynamic contrast-enhanced MR imaging in differentiating venous from nonvenous malformations were determined.

RESULTS

Excellent agreement between the two observers in determining MR categories (gamma = 0.99) existed. Agreement between MR categories and angiographic categories was high for both observers (gamma = 0.97 and 0.92). Sensitivity of conventional MR imaging in differentiating venous and nonvenous malformations was 100%, whereas specificity was 24-33%. Specificity increased to 95% by adding dynamic contrast-enhanced MR imaging, but sensitivity decreased to 83%.

CONCLUSION

Conventional and dynamic contrast-enhanced MR parameters can be used in combination to categorize vascular malformations. Dynamic contrast-enhanced MR imaging allows diagnosis of venous malformations with high specificity.