Clinical outcome and predictors of treatment response in foam sodium tetradecyl sulfate sclerotherapy of venous malformations

Injectable chitosan hydrogel effectively controls lesion growth in a venous malformation murine model

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of intralesional injection of chitosan hydrogel (CH) combined with sodium tetradecyl sulfate (STS) to sclerose and embolize venous malformations (VMs) by comparison with 3% STS foam and placebo in a mouse model.

MATERIALS AND METHODS

Subcutaneous VMs were created by injecting HUVEC_TIE2-L914F cells, mixed with matrigel, into the back of athymic mice (Day [D] 0). After VM-like lesions were established at D10, 70 lesions were randomly assigned to one of six treatment groups (untreated, saline, 3% STS-foam, CH, 1% STS-CH, 3% STS-CH). For 3% STS-foam, the standard Tessari technique was performed. VMs were regularly evaluated every 2-3 days to measure lesion size until the time of collection at D30 (primary endpoint). At D30, VM lesions including the matrigel plugs were culled and evaluated by histological analysis to assess vessel size, chitosan distribution and endothelial expression. One-way analysis of variance (ANOVA) test was performed to compare quantitative variables with normal distribution, otherwise Kruskal-Wallis test followed by pairwise comparisons by a Wilcoxon rank sum test was performed.

RESULTS

All VMs were successfully punctured and injected. Six VMs injected with 3% STS-CH showed early skin ulceration with an extrusion of the matrigel plug and were excluded from final analysis. In the remaining 64 VMs, skin ulceration occurred on 26 plugs, resulting in the loss of three 3% STS-foam and one 1% STS-CH plugs. Both chitosan formulations effectively controlled growth of VMs by the end of follow-up compared to untreated or 3% STS-foam groups (P < 0.05). Vessel sizes were smaller with both CH formulations compared to untreated and saline groups (P < 0.05). Additionally, there were smaller vascular channels within the 1% STS-CH group compared to the 3% STS-foam group (P < 0.05).

CONCLUSION

Chitosan's ability to control the growth of VMs suggests a promising therapeutic effect that outperforms the gold standard (STS-foam) on several variables.

Microwave ablation with hydrodissection used for the treatment of vascular malformations: effectiveness and safety study

Object

The aim of the study was to investigate the safety, effectiveness, and peripheral nerve protection in ultrasound-guided microwave ablation (US-guided-MWA) for vascular malformations (VMs) closely related to peripheral nerve.

Materials and methods

From August 2019 to February 2022, 31 patients with 39 VMs received US-guided-MWA. All lesions were confirmed to be closely related to the peripheral nerve by imaging evaluation. Hydrodissection was applied to protect surrounding normal tissue, including peripheral nerves. The patients were followed up at 1day, 2 days, 3 days, 1 week, 1 month, 3 months after operation. Measurements of lesion volume, volume reduction ratio (VRR), sensory and functional abnormalities of adjacent nerves, number of treatments, complication details, personal satisfaction, recurrence, and symptom improvement were recorded.

Results

Among the 39 VMs, the maximum volume is 128.58ml, while the minimum volume is 0.99ml. After a mean follow-up of 13.06 ± 4.83 months, the mean numerical rating scale (NRS) score decreased from 5.13 ± 1.65 to 0.53 ± 0.83 (P<0.0001). The mean mass volume was reduced from 18.34 ± 24.68 ml to 1.35 ± 2.09 ml (P=0.0001). The VRR of all lesions was 92.06%. However, the mean number of treatments was only 1.64 ± 0.87. All patients were satisfied with the technique, with a mean satisfaction score (SC) of 9.23 ± 1.13. There were no motor function abnormalities of the related nerves. 10 patients felt numbness in the ablation area after ablation, and gradually recovered after 1 month.

Conclusion

US-guided-MWA serves as a novel alternative approach for patients with VMs. Preoperative evaluation of the relationship between VMs and peripheral nerves combined with intraoperative hydrodissection is an effective and safe method to prevent nerve injury.

Comparison of bleomycin polidocanol foam vs electrochemotherapy combined with polidocanol foam for treatment of venous malformations

OBJECTIVE

This study aims to investigate the difference in safety and efficacy between two treatments for venous malformations (VMs), electrochemotherapy combined with polidocanol foam (ECP) and bleomycin polidocanol foam (BPF), providing alternative therapies for VMs.

METHODS

We conducted a retrospective review of 152 patients with VMs treated with ECP and BPF. Pre- and post-treatment magnetic resonance images (MRIs) were collected, and clinical follow-up assessments were performed. Imaging results were used to calculate lesion volume changes. Clinical outcomes included changes in pain and improvements in perceived swelling. Patients were followed up at 1 week and 6 months after surgery. All emerging complications were documented in detail.

RESULTS

Of the 152 patients, 87 (57.2%) received BPF treatment, and 65 (42.8%) received ECP treatment. The most common location of VMs was the lower extremities (92/152; 60.2%), and the most common symptom was pain (108/152; 71.1%). Forty-three patients had previously undergone therapy in the BPF group (43/87; 49.4%), whereas 30 patients had received prior treatment in the ECP group (30/65; 46.2%). The study found that the percentage of lesion volume reduction in the BPF group was not significantly different from that in the ECP group (75.00% ± 17.85% vs 74.69% ± 8.48%; P = .899). ECP was more effective when the initial lesion volume was greater than 30 mL (67.66% ± 12.34% vs 73.47% ± 8.00%; P = .048). Patients treated with BPF had significantly less posttreatment pain than those treated with ECP, in different baseline lesion size. In the overall sample, pain relief was significantly higher in the BPF group than in the ECP group (4.21 ± 1.19 vs 3.57 ± 0.76; P = .002). However, there was no difference in pain relief between the two groups for the treatment of initially large VMs (4.20 ± 0.94 vs 3.70 ± 0.87; P = .113). The ECP group was significantly more likely to develop hyperpigmentation (5/87; 5.75% vs 11/65; 16.92%; P = .026) and swelling (9/87; 10.34% vs 16/65; 24.62%; P = .019) 1 week after surgery than the BPF group.

CONCLUSIONS

Our study demonstrates that both BPF and ECP are effective treatments for VMs, with BPF being a safer option. ECP is a better choice for patients with the initial lesion volume greater than 30 mL, but it is more likely to lead to early swelling and hyperpigmentation.

Wide Resection for Pediatric Extremity Vascular Malformation-A Tertiary Hospital's Experience

BACKGROUND

Vascular malformations of the extremities (VM) are common benign lesions that tend to grow throughout the patient's lifetime. They can cause various issues like pain, swelling, and even limb length discrepancies. Sclerotherapy was the preferred treatment choice in previous studies. However, sclerotherapy and many other treatments have the potential to result in higher recurrence rates. Surgical treatment has been shown to be effective and safe in many cases. Hence, this study aims to evaluate the suitability of wide resection surgery for VM to reduce recurrence.

METHODS

Fort-seven VM cases that underwent wide resection were identified retrospectively in the institution of study. Demographics, depth of malformation, whether malformations were local or diffuse, location and size of malformations, and histology records were taken note of. Records of recurrence and postoperative function were also gathered. We utilized self-reported questionnaires, QuickDASH and Lower Extremity Functional Scale, to determine patients' postsurgical physical function.

RESULTS

Out of 47 cases that underwent wide resection, we found a recurrence rate of 2.1%. No patients sustained any loss of function postsurgery, with few patients experiencing minor complications like tenderness, hypertrophic scars/keloids, as well as numbness. Good functionality posttreatment was also seen through self-reported questionnaires, with an average score of 2.12 for QuickDASH and 99.96% for LEFS.

CONCLUSION

Where margins can be obtained without functional impairment, surgical-wide resection for VM is a viable treatment option to minimize recurrence.

LEVEL OF EVIDENCE

Level-IV.

Clinical outcomes and predictors of bleomycin polidocanol foam sclerotherapy treatment response in venous malformations

OBJECTIVE

To evaluate the safety and efficacy of bleomycin polidocanol foam (BPF) sclerotherapy for venous malformations (VMs) and analyze the associated clinical outcomes and predictors.

METHODS

We retrospectively assessed BPF sclerotherapy outcomes in 138 patients with VMs. We analyzed pain levels, lesion volume reduction, and subjective perception of response. Logistic regression analysis was performed to identify potential predictors of treatment outcome. Additionally, we carefully monitored and recorded complications.

RESULTS

There was a notable average reduction in lesion volume by 78.50% ± 15.71%. The pain numerical rating scale (NRS) score decreased from 4.17 ± 2.63 prior to treatment to 1.05 ± 1.54 afterward, and 70.3% of the patients experienced effective relief after a single BPF treatment. Multivariate analysis revealed that a high baseline NRS (odds ratio [OR]:  4.026) and elevated activated partial thromboplastin time (APTT, OR: 1.200) were positive predictors of pain reduction. Additionally, a high baseline NRS score (OR: 1.992) and elevated thrombocytocrit (PCT, OR: 2.543) were positive predictors of incomplete postoperative pain relief. Minor complications occurred in 31 (22.46%) patients.

CONCLUSION

BPF sclerotherapy is safe and effective for VMs, resulting in significant reduction in lesion volume, improved symptoms, and minimal complications. APTT and PCT levels are important predictors of pain outcomes following BPF treatment.

A systematic review and network meta-analysis of the effectiveness of sclerotherapy for venous malformation

OBJECTIVE

Sclerotherapy for venous malformation has been widely used; however, no guidelines are available to assess the effectiveness of different sclerotherapy agents. We conducted a systematic review and network meta-analysis to investigate the effectiveness of sclerotherapy agents for venous malformations.

METHODS

Three electronic databases were searched from their inception (1950) to April 29, 2021. Studies comparing the effectiveness of different sclerotherapy agents were included. The risk of bias within and across studies was assessed. Pairwise meta-analyses were conducted, followed by a network meta-analysis. We also assessed inconsistency and publishing bias using various approaches.

RESULTS

Seven studies with 547 patients in six arms were included in the present study. We defined the response and complete response as two separate outcomes. Significant differences were observed in four comparisons with respect to the response (ethanol vs bleomycin, ethanol vs polidocanol, ethanol vs sodium tetradecyl sulfate, polidocanol vs sodium tetradecyl sulfate). No statistically significant differences were found in the other comparisons. The evidence network revealed that for the response outcome, ethanol ranked first, followed by pingyangmycin, polidocanol, sodium morrhuate, bleomycin, and, finally, sodium tetradecyl sulfate. For the complete response outcome, pingyangmycin had the best results, followed by sodium morrhuate, polidocanol, ethanol, bleomycin, and, finally, sodium tetradecyl sulfate. Major complications, such as facial nerve palsy, serious local swelling, and necrosis, had occurred mostly in the ethanol group and rarely in the other groups. Because of the limited data, no further analysis of major complications was conducted. Our confidence in the comparisons and rankings was low. We found no verified inconsistency or publishing bias in the present study using the existing approaches.

CONCLUSIONS

Ethanol showed a significantly better response statistically compared with the other agents. However, ethanol had also resulted in the highest incidence of complications. Pingyangmycin showed the second-best response, best complete response, and a low rate of complications, respectively. Overall, pingyangmycin achieved excellent performance and balance in terms of the different outcomes. However, they could not be adequately recommended from the available data. More superior trials, especially randomized controlled trials, are needed in the future.

Factors Affecting Adverse Events after Venous Malformation Sclerotherapy

PURPOSE

To evaluate factors that contribute to adverse events (AEs) after embolization of venous malformations (VMs) using sclerosing agents.

MATERIALS AND METHODS

A retrospective review of patients who underwent direct puncture embolization of VMs with a sclerosing agent and adjunctive techniques, also termed as sclerotherapy, from 2016 to 2021 was performed. Three-hundred one embolizations in 137 patients (median age, 19.0 years; interquartile range, 12.8-31.5 years) were evaluated. The VM characteristics and embolization details were analyzed. Anticoagulation was also evaluated based on D-dimer levels. Cutaneous and noncutaneous AEs were analyzed. The AEs were categorized using Society of Interventional Radiology guidelines.

RESULTS

VMs involving tissue planes were subcutaneous (n = 104), intramuscular (n = 84), and combined (n = 113). Overlying skin involvement was observed in 56% of the patients. Sodium tetradecyl sulfate was mainly used (83%). Periprocedural anticoagulation was used in 9% of the patients. Most AEs were minor (30/301, 9.7%), and only 1.7% (5/301) were major (21 cutaneous and 14 noncutaneous AEs). Age below 18 years (odds ratio, 4.4502; 95% confidence interval, 1.5607-12.6890; P = .0052) and overlying skin involvement (odds ratio, 7.1794; 95% confidence interval, 1.6226-31.7656; P = .0094) were factors associated with cutaneous AEs. All noncutaneous AEs developed in patients with intramuscular VMs; however, this association was not statistically significant. There was no severe hematologic AE or permanent consequence.

CONCLUSIONS

The overall AE rate after VM embolization was 11.6%; however, major AEs were rare (1.7%). Cutaneous AEs were associated with young age and overlying skin involvement. All noncutaneous AEs developed in patients with intramuscular VMs.

Venous Malformations

Venous malformations, the most common type of vascular malformation, are slow-flow lesions resulting from disorganized angiogenesis. The International Society for the Study of Vascular Anomalies (ISSVA) classification offers a categorization scheme for venous malformations based on their genetic landscapes and association with congenital overgrowth syndromes. Venous malformations present as congenital lesions and can have broad physiologic and psychosocial sequelae depending on their size, location, growth trajectory, and tissue involvement. Diagnostic evaluation is centered around clinical examination, imaging evaluation with ultrasound and time-resolved magnetic resonance imaging, and genetic testing for more complex malformations. Interventional radiology has emerged as first-line management of venous malformations through endovascular treatment with embolization, while surgery and targeted molecular therapies offer additional therapeutic options. In this review, an updated overview of the genetics and clinical presentation of venous malformations in conjunction with key aspects of diagnostic imaging and treatment are discussed.

Sclerotherapy as an alternative treatment for complex, refractory seromas

Traditional therapy for seromas often entails compression, aspiration, drainage, or surgical excision and re-closure; however, more complex, treatment-refractory seromas may require additional treatment. Sclerotherapy has been well documented in the treatment of simple pleural effusions, vascular malformations, lymphoceles and seromas. However, little evidence is available on the efficacy of sclerotherapy in complex, treatment-refractory seromas that develop post-operatively in patients with complex medical histories. We present a case series highlighting the use of sclerotherapy by interventional radiology as an alternative or adjunctive treatment method for chronic, high-volume post-operative seromas recalcitrant to multiple attempts of traditional treatment. At long-term follow-up, the seromas resolved after a maximum of four rounds of sclerotherapy with various combinations of known sclerosants. Highly complex cases of large, chronic seromas may be refractory to conservative modalities and re-closure. Sclerotherapy can be considered an alternative method or adjunctive treatment for chronic, recalcitrant post-operative seromas.

Percutaneous Cryoablation of Lower Limb Soft-Tissue Venous Malformations: Preliminary Results of Long-Term Efficacy

PURPOSE

To retrospectively evaluate long-term efficacy of percutaneous cryoablation for lower limb soft-tissue venous malformations.

MATERIALS AND METHODS

Nine patients (mean age, 36.6 years) with lower limb soft-tissue venous malformations were included. Cryoablation was performed percutaneously using an argon-based system. Adverse events (AE) using the Common Terminology Criteria for AEs version 4.0 were evaluated. The visual analog scale (VAS) scores and lesion volumes measured on magnetic resonance imaging were also evaluated at 12 months and 5-6 years.

RESULTS

Technical success (i.e., complete coverage of the lesion by an iceball) was achieved in eight of the nine patients. All patients developed a total of 14 grade 1 or 2 adverse events. The mean (± standard deviation) VAS score was 6.0 (± 1.7) before therapy, whereas it was 0.14 (± 0.27) at 12 months and 0.97 (± 1.3) at 5-6 years (58-78 months). Complete pain relief was obtained in 6 and 5 patients at 12 months and 5-6 years, respectively. The median lesion volume was 2.49 mL before therapy, whereas it was 0.26 mL at 12 months and 0.35 mL at 5-6 years.

CONCLUSION

Percutaneous cryoablation of lower limb soft-tissue venous malformations achieved considerable pain relief and lesion shrinkage for 5-6 years in this small preliminary study.

LEVEL OF EVIDENCE

Level 4, Case Series.

Balloon occlusion as an adjunctive technique during sclerotherapy of Puig's classified advanced venous malformations

OBJECTIVE

Puig types 2 through 4 venous malformations (VMs) are challenging to treat with sclerotherapy given their robust systemic outflow. Endovenous balloon occlusion offers a means of temporarily occluding systemic venous outflow to allow for more complete sclerotherapy. This study reviews our experience of implementing this technique in patients with Puig advanced (types 2 through 4) VMs.

METHODS

An IRB approved review of treated venous malformations from 2013-2016 revealed 10 patients fitting inclusion criteria. Patient demographics, pre-procedural imaging, intra-procedural technical parameters, and post-procedural follow-up outcomes were recorded. All patients underwent temporary balloon occlusion of a systemic or major draining vein during sclerotherapy. Embolic agents included n-butyl cyanoacrylate glue, sodium tetradecyl sulfate foam, and coils. Standard 5 French angioplasty balloons ranged from 4 to 8 mm diameter and 2 to 8 cm length depending on vessel requiring occlusion. All patients underwent minimum 3-year follow-up questionnaire administration re-assessing resolution of lesion symptomology and post-procedural quality of life (QoL) measures.

RESULTS

Of the 10 VMs treated, 2 were Type 2, 6 were Type 3, and 2 were Type 4. More than one sclerotherapy session was required in 7/10 patients (mean: 2, range: 1-4). Most common sites of VM systemic drainage included subclavian, popliteal, internal/external jugular, and basilic veins. All patients had no indication for further sclerotherapy following adjunctive balloon occlusion. No non-target embolization or immediate post-procedural complications occurred. Follow-up questionnaires (mean interval: 3 years 6 months, range: 3 years-3 years 11 months) confirmed the persistence of embolization effects, improved QoL, and no additional sclerotherapy sessions for all patients in the cohort.

CONCLUSIONS

Endovenous balloon occlusion as an adjunct to sclerotherapy can be considered when treating patients with types 2-4 venous malformations. This technique lowers the risk of non-target systemic venous embolization, allowing for operator-driven deeper intralesional sclerosant penetration and subsequently maintained treatment efficacy.

A Prospective Randomized Controlled Trial Using Propofol or Dexmedetomidine for Conscious Sedation in Pediatric Patients Undergoing Sclerotherapy

Aim:

Sodium tetradecyl sulfate (STS) sclerotherapy in pediatric patients is usually undertaken under sedation inside digital subtraction angiography (DSA) suite. These patients are day-care patients and need adequate sedation for small duration. We performed this study to compare propofol and dexmedetomidine as sedative agents in these patients.

Materials and Methods:

Seventy American Society of Anesthesiologists (ASA) physical status I patients scheduled to undergo sclerotherapy for low-flow venous malformations under sedation were randomized to be administered either dexmedetomidine (Group D) or propofol (Group P). In Group D, initially 2 µg/kg of dexmedetomidine was administered over 10min (or till attainment of a Ramsay sedation score [RSS] of 5), followed by an infusion at the rate of 0.3 µg/kg/h. In Group P, propofol 1mg/kg bolus followed by an infusion at 100 µg/kg/min was administered, titrated to an RSS of 5. We measured intraoperative heart rate, blood pressure, respiratory rate, duration of procedure, and incidence of arterial desaturation, bradycardia, and respiratory depression in the two groups.

Results:

All the patients in both groups completed the procedure. The mean anesthesia time was significantly longer in Group D. Intraoperative heart rates remained comparable in the two groups, whereas systolic and diastolic BP were significantly higher in Group D throughout the procedure. No patient in Group D experienced arterial desaturation, whereas five patients in Group P reported a SpO₂ of <90%.

Conclusion:

Both propofol and dexmedetomidine can be used for administering sedation in pediatric patients undergoing sclerotherapy for superficial venous malformations in DSA suite. Although propofol provides a rapid onset and reduced duration of action, dexmedetomidine provides reduced episodes of arterial desaturation and respiratory depression.

Use of percutaneous foam sclerotherapy with 1.5% sodium tetradecyl sulfate for treatment of a pelvic limb venous malformation in a dog

CASE DESCRIPTION

A 6-year-old 17-kg (37.4-lb) spayed female mixed-breed dog was evaluated because of swelling and intermittent lameness of the right pelvic limb and perianal and vulvar bleeding caused by a suspected arteriovenous malformation.

CLINICAL FINDINGS

The right pelvic limb had a diffuse, raised, cobblestone-like appearance with lameness, edema, and multifocal ulcerations. The abdominal skin had multifocal circular erythematous lesions, the perianal region was erythematous, and the vestibule had superficial distended vessels. Ultrasonography and CT did not reveal the presence of an arteriovenous malformation; however, digital subtraction venography confirmed the presence of a venous malformation (VM) throughout the limb.

TREATMENT AND OUTCOME

A mixture of foam sclerosant (1.5% sodium tetradecyl sulfate) and contrast medium was agitated with air and injected percutaneously into the VM. The dog received an injection of corticosteroid solution, and a soft-padded bandage was applied to the limb for 3 days. Six weeks later, the dog would intermittently hop when running, and the limb was mildly edematous with ecchymotic lesions; the swelling and lameness had improved considerably. Perianal and vulvar bleeding and dilation of the vestibular vessels had resolved. At 21 months after the procedure, examination revealed no right pelvic limb lameness related to the VM; only small cyst-like lesions and edema around the tarsus remained.

CLINICAL RELEVANCE

The favorable clinical outcome for this dog for a 21-month period after treatment of a pelvic limb VM with foam sclerotherapy has suggested that foam sclerotherapy may be used to successfully treat limb VMs in some dogs.

Imaging assessment and treatment of soft-tissue venous malformations: Retrospective case series study of 126 cases

Venous malformations (VMs) are common slow-flow vascular malformations, which affect almost anywhere of the body. From January 2010 to October 2019, 126 patients with VMs who had complete imaging and follow-up data were enrolled into this study, including 75 males. The initial treatment age ranged from 5 to 72 years. The role of imaging results on the choice of treatment measures and the application were summarized. In this study, we retrospectively analyzed the imaging examinations, treatment measures, and follow-up results of the patients with VMs in our clinic. In this series, imaging examinations included ultrasound, magnetic resonance imaging, computed tomography (CT) scan and enhanced scan, percutaneous sinus angiography and three-dimensional CT imaging, plain film, CT venography, CT angiography, and digital subtraction angiography. Treatment measures included surgical excision (n = 20), sclerotherapy (n = 86, including absolute ethanol [n = 75], polidocanol [n = 8], and pingyangmycin [n = 3]), and combination treatment with intralesional copper wire retention and sclerotherapy(n = 20). After treatment, most of the lesions shrunk obviously or disappeared, and the symptoms were largely relieved. Comprehensive and accurate imaging assessment of VMs is necessary for selecting appropriate treatment. Individual strategy and sequential treatment can achieve effective results and avoid potential complications.

Safety and efficacy of foam sclerotherapy for treatment of low-flow vascular malformations in children

OBJECTIVE

Congenital vascular malformations are a heterogeneous group of lesions with the potential to cause significant lifelong morbidity in children. Diagnosis and treatment of these lesions may be complex and require a multidisciplinary approach. Sclerotherapy is widely used for the treatment of low-flow vascular malformations (LFVMs) as an alternative to surgical resection in adults; however, limited data of its use in a pediatric setting are available. The purpose of this study was to evaluate the efficacy and safety of sclerotherapy for pediatric LFVMs.

METHODS

In this retrospective study, we reviewed our multidisciplinary vascular malformations team database for all patients younger than 18 years treated for congenital vascular malformations from 2008 to 2017. Of these, patients with LFVM treated with foam sclerotherapy were included. Dynamic contrast-enhanced magnetic resonance imaging was used to select patients for sclerotherapy by the multidisciplinary team. Foam sclerotherapy was performed with either polidocanol or sodium tetradecyl sulfate. Patients' characteristics, including demographics, presenting symptoms, and anatomic location of malformation, were assessed. Outcomes included treatment response, number of procedures, and postprocedural complications.

RESULTS

The 61 patients with 61 LFVMs included 27 boys (44.3%) and 34 girls (55.7%), with mean age of 10.3 years (standard deviation, ± 5.3 years). The cohort included 32 venous (52.5%), 16 lymphatic (26.2%), and 8 mixed venous and lymphatic (13.1%) malformations along with 5 (8.2%) associated with Klippel-Trénaunay syndrome. Primary indications for intervention included pain and swelling (n = 12 [19.6%]), pain alone (n = 23 [37.7%]), swelling alone (n = 15 [24.6%]), functional impairment (n = 8 [13.1%]), and bleeding (n = 3 [4.9%]). Anatomic distributions varied, with 13 head and neck (21.3%), 5 truncal (8.2%), 10 upper extremity (16.4%), 27 lower extremity (44.3%), and 6 diffuse (9.8%). Among the head and neck lesions, 8 (13.1%) extended to the face; and of the extremity lesions, 5 (8.2%) extended to the hand and 17 (27.9%) to the foot. Overall, sclerotherapy resulted in significant improvement or complete resolution of symptoms in 53 patients (86.9%). Complications were observed in seven patients (11.4%); six cases (9.8%) of superficial skin ulceration resolved without intervention, and one infection (1.6%) required antibiotics. No patients experienced adverse hemodynamic consequences or venous thromboembolism.

CONCLUSIONS

This series of pediatric LFVMs, the largest of its kind to date, demonstrates that sclerotherapy with foam-based agents effectively reduces symptoms with an acceptable rate of complications. Further study is needed to determine the optimal sclerosing agents for individual subsets of LFVMs in the pediatric population.

Sclerotherapy for eyelid and anterior orbital venous-lymphatic malformation

PURPOSE

To assess the efficacy of sclerotherapy with sodium tetradecyl sulfate (STS; Fibrovein 1%) in superficial periocular venous and lymphatic malformations.

METHODS

Eleven patients with low-flow venous and lymphatic malformations with extension predominantly to the eyelids, conjunctiva, and anterior orbit were selected. Sclerotherapy with STS was undertaken as an office-based procedure without any radiological guidance. Injections were repeated every 4 weeks until desired response occurred. Therapeutic effect was assessed objectively by change in the size of the lesions in serial photography.

RESULTS

The lesions completely resolved in 4 cases with small eyelid and fornix lesions. In other 7 cases there was partial resolution to less than half of primary size. We did not have any significant complications.

CONCLUSION

Sclerotherapy with STS is an easy and effective modality for treatment of venous-lymphatic malformations and can be undertaken as an office-based procedure in lesions which are limited to eyelids and anterior orbit.

Risk Factors for Macroscopic Haemoglobinuria After Sclerotherapy Using Ethanolamine Oleate for Venous Malformations

OBJECTIVES

Sclerotherapy is an essential component of the treatment for venous malformations, and ethanolamine oleate (EO) is known as a useful sclerosing agent. However, macroscopic haemoglobinuria (MH) and subsequent renal impairment are severe complications after sclerotherapy using EO. The present study aimed to clarify the MH risk factors for better peri-operative management of venous malformations.

METHODS

Data collected during 130 procedures involving 94 patients who were undergoing sclerotherapy using EO for venous malformation were retrospectively analysed. Pre-operative and operative variables, including sex, age, pre-operative body mass index, location, depth, type of lesion, size, number of procedures, type of drainage vein, ratio of sclerosant to air, and injected total dose of 5% EO per body weight (BW), were examined. Univariable analysis and multivariable logistic regression were performed to determine the possible risk factors for MH.

RESULTS

Following sclerotherapy, MH occurred in 27.7% of patients, but no patient developed post-operative renal impairment because of aggressive hydration and haptoglobin administration. On univariable analysis, diffuse lesion, lesion size ≥50 cm², and total injected dose of 5% EO ≥ 0.18 mL/kg were found to be the MH risk factors. Multivariable logistic regression analysis identified a total injected dose of 5% EO ≥ 0.18 mL/kg as the significant independent factor contributing to MH risk.

CONCLUSIONS

Macroscopic haemoglobinuria is a reversible complication if immediate and appropriate interventions with aggressive hydration and haptoglobin administration are performed; therefore, it should be closely monitored following sclerotherapy, especially when using 5% EO ≥ 0.18 mL/kg.

Craniofacial venous malformations treated by percutaneous sclerotherapy using polidocanol: a single-center experience

BACKGROUND

Percutaneous therapy with various sclerosants is an established treatment of venous malformations in general. We investigated the safety and effectiveness of polidocanol in the craniofacial region.

PURPOSE

To present and evaluate our subjective and objective mid- and long-term results of patients with craniofacial venous malformations (CFVM) after percutaneous sclerotherapy using polidocanol.

MATERIAL AND METHODS

Twenty patients with CFVM treated by percutaneous sclerotherapy were followed up and asked to fill in a questionnaire comparing levels of the following CFVM-related symptoms before and after treatment: pain; functional impairment; cosmetic deformities; and impairment in daily life. Additionally, both size reduction as well as procedural-related complication rates were analyzed.

RESULTS

Evaluation of the questionnaire revealed an improvement or complete relief of CFVM-related symptoms with significant reduced impairment in daily life after percutaneous sclerotherapy. Eighteen (90%) patients noticed a post-sclerotherapy improvement of at least one of their corresponding symptoms and expressed satisfaction with regard to their treatment. For 13 patients, a > 50% size reduction of the CFVM could be observed, while seven exhibited a < 50% size reduction. One minor complication was encountered in 56 treatment sessions (1.8%).

CONCLUSION

Percutaneous sclerotherapy using polidocanol is a well-tolerated treatment for CFVM with a low complication rate. Size reduction and positive results with improvement of different clinical symptoms can be achieved.

Sclerotherapy for intramuscular vascular malformations: A single-center experience

BACKGROUND

Vascular malformations isolated to skeletal muscles are rare and often debilitating due to pain and very challenging to treat. Multi-modal management options include compression garments, medical therapy, sclerotherapy, and surgical resection.

METHODS

A retrospective review of patients who underwent sclerotherapy for intramuscular venous malformations (IVM) between 2008 and 2016 was performed. Demographics, indications, and clinical follow-up were analyzed.

RESULTS

Twenty patients underwent sclerotherapy for IVM. Six males and 14 females underwent 58 procedures. All patients presented with pain and were treated initially with compression garments. Median age at first treatment was 13years (+/- 5.06years). Initial protocol consisted of 2 sclerotherapy procedures with sodium tetradecyl sulfate (STS) within a 2-3month interval. Median volume of the lesion was 40cm³ (+/- 28.7), mostly located in the lower extremities (15/20). Median number of treatments was 2 (+/- 1.95). Treatment prior to puberty resulted in a median symptom-free time of 4years (+/- 2.18), while after puberty resulted in a symptom-free time of 2years (+/- 2.28). Two patients had an underlying coagulopathy and were admitted for observation and peri-procedural Lovenox. No procedure related complications were noted with a median follow-up of 4years (+/- 2.27).

CONCLUSION

IVMs are rare but can be incapacitating secondary to pain. Sclerotherapy is a useful minimally invasive procedure generally requiring at least two consecutive treatments. Treatment of patients prior to puberty appears to provide a more durable result, and surgical resection may be avoided.

TYPE OF STUDY

retrospective.

LEVEL OF EVIDENCE

IV.

Complications After Treatment of Head and Neck Venous Malformations With Sodium Tetradecyl Sulfate Foam

PURPOSE

The aim of this study was to evaluate complications in patients with head and neck venous malformations (VMs) treated with foam sclerotherapy using sodium tetradecyl sulfate (STS).

METHODS

The authors retrospectively evaluated the complications, pain. and degree of satisfaction in 69 consecutive patients affected by cervicofacial VM managed with STS using the Tessari method in a single institution.

RESULTS

The average number of procedures for each patient was 2.1. The most frequent complication was blistering. We observed 1 patient of temporary weakness of a facial nerve branch, 1 paradoxical embolism, and 1 orbital compartment syndrome.The average pain score was 0 (no pain at all) (51.5%). There was no statistically significant correlation between patient satisfaction and the presence of complications or the degree of pain.

CONCLUSIONS

Sclerotherapy with STS is an effective treatment that yields to very high patient satisfaction. This procedure has an overall low complication rate and is usually effective within a few sessions. However, severe complications may occur; these must be pointed out in the informed consent and the surgeon must be aware of and ready to quickly treat them to prevent long-term sequelae.

Liquid and Foam Sclerotherapy for Spider and Varicose Veins

Sclerotherapy has wide applicability in treating venous disease at every stage of clinical disease. The various sclerosant drugs and formulations each have unique properties, utilities, and side effects. Treating physicians should be aware of the differences between agents, accounting for disease presentation, vein characteristics, and patient comorbidities when selecting the appropriate sclerosing agents. Successful outcomes rely on proper patient evaluation and assessment for contraindications to sclerotherapy. Thorough patient education regarding realistic expectations with sclerotherapy in terms of symptoms relief, recurrence, and improvement in appearance is of chief importance.

Ethanol-Gel Sclerotherapy of Venous Malformations: Effectiveness and Safety

OBJECTIVE

In the treatment of venous malformations, ethanol may be administered in a gelified form to increase local effects and reduce systemic ones. The purpose of this prospective study was to evaluate the efficacy and safety of a commercially available viscous ethanol gel in the treatment of venous malformations.

SUBJECTS AND METHODS

Thirty-one patients (mean age, 23.4 years; age range, 6.6-46.5 years) with venous malformations were prospectively scheduled for two ethanol-gel sclerotherapy sessions. Venous malformations were located at the lower extremity (n = 18), the upper extremity (n = 9), and the face (n = 4). Questionnaires to assess pain, clinical examinations, professional photographs, and contrast-enhanced MRI of the venous malformations were performed before and after therapy to measure therapy-induced changes. Two experienced radiologists blinded to the examination date and clinical status compared photographs and MR images before and after treatment.

RESULTS

A mean of 4.2 mL of ethanol gel were administered per session. The technical success rate was 100%. Clinical success, defined as improvement or resolution of symptoms, was noted in 81% of patients. Mean pain score decreased, and the difference was statistically significant (3.9 vs 3.1, p = 0.005). In 54 treatment sessions where follow-up was available, four minor complications occurred. Comparison of photographs and MR images before and after treatment showed improvement in 35% and 93% of patients, respectively.

CONCLUSION

Ethanol gel is an effective and safe sclerosing agent in the treatment of venous malformations.

[Vascular medicine and foam sclerotherapy for venous malformations]

Vascular medicine plays a determining role in the management of vascular malformation, especially venous malformations. Ideally, therapeutic decision should be made in a multidisciplinary staff meeting. Vascular medicine plays the leading role for diagnosis and duplex-Doppler evaluation of coagulation disorders, potentially associated with an assessment of treatment feasibility using chemical or thermic endovascular techniques. Potential adherence of compression therapy must also be evaluated. Decision trees often mention sclerotherapy for the management of venous malformations. Echo-guided foam sclerotherapy is preferred. The superiority of foam sclerotherapy over liquid sclerotherapy has been demonstrated. Indications and limitations of this specific treatment remain to be definitively determined, especially for treatments with radiological control. Side effects are now well described for the use of foam sclerotherapy for venous malformations. They remain limited. Future developments should help optimize the sclerosing effect of currently used foams or other products to be developed. For the vascular medicine specialist, the main contribution is to define the appropriate use of echo-guided sclerotherapy.