Percutaneous sclerotherapy of vascular malformations in children using sodium tetradecyl sulphate: the Birmingham experience

How Diluted Liquid Sodium Tetradecyl Sulphate Works in Varices with Competent Superficial Valves Versus Stockings Alone

BACKGROUND AND OBJECTIVE

Varicose veins are the most common complaints of referrals to vascular surgeons. Upon the cause, liquid sclerotherapy could be an efficient solution first in regard to competent main superficial valves. To find the impact of diluted liquid sclerotherapy in varices in patients with no superficial valve refluxes compare to whom wearing only stockings.

MATERIALS AND METHODS

Sclerotherapy with 0.3-0.5% liquid form of Sodium Tetradecyl Sulphate (STS) for reticular and spider varicosis, ulcers feeder veins and grade 3-4 sporadic varices were used. Patient's complaints the zone prevalence, response and satisfactoriness were detected clinically and data compared between the two injected cases and who managed by stockings alone with >1 year follow up.

RESULTS

Two groups (156 sclerotherapy, 76 only stockings) with three classifications for severity were obtained. Complete recovery of all varices and ulcers were almost achieved with no considerable complication. Logical regression test in unilateral to bilateral varices predict about 70% more recovery (p = 0.048), mild to severe 85% more (p<0.001), moderate to severe 29% more (p = 0.008) and 10-15% response for severe cases. No significant difference for ages and responses between the 2 groups was existed.

CONCLUSION

Diluted liquid sclerotherapy by STS was shown efficient in all ranges of varices. Stockings alone also were adequate to relief symptoms compare to sclerotherapy.

The Addition of Lipid-Based Contrast Medium does not Inactivate the Detergent Sclerosant Sodium Tetradecyl Sulfate in-vitro

PURPOSE

To investigate if the detergent sclerosant sodium tetradecyl sulfate (STS) is deactivated by the lipid-based contrast agent ethiodised oil.

METHOD

3% STS was mixed with ethiodised oil and room air in a 2:1:4 ratio in two luer lock syringes and a three way connector and agitated to make foam (the Tessari technique) to replicate the clinical use of the products. The assay of STS in the mixture was assessed using the British Pharmacopoeia method. Briefly this is a manual titration method where the solution of STS is mixed with an indicator solution and titrated with hyamine solution of known concentration; the concentration of the STS can then be calculated with the titration results. To further mimic the clinical environment with the presence of blood, the effect of adding increasing amounts of albumin to the STS-ethiodised oil mixture was assessed.

RESULTS

The assay of STS in the solution after mixing with ethiodised oil was 3% indicating that the ethiodised oil did not deactivate the STS. The addition of albumin to the STS-contrast mixture resulted in near linear neutralisation of the STS with increasing concentrations in the same quantities as with STS alone.

CONCLUSIONS

The mixture of the lipid-based contrast agent ethiodised oil with the detergent sclerosant STS did not affect the availability of the sclerosant. The continued use of STS-ethiodised oil in the management of vascular malformations can be supported.

Recent Progress in Lymphangioma

Lymphangioma is a common type of congenital vascular disease in children with a broad spectrum of clinical manifestations. The current classification of lymphangioma by International Society for the Study of Vascular Anomalies is largely based on the clinical manifestations and complications and is not sufficient for selection of therapeutic strategies and prognosis prediction. The clinical management and outcome of lymphangioma largely depend on the clinical classification and the location of the disease, ranging from spontaneous regression with no treatment to severe sequelae even with comprehensive treatment. Recently, rapid progression has been made toward elucidating the molecular pathology of lymphangioma and the development of treatments. Several signaling pathways have been revealed to be involved in the progression and development of lymphangioma, and specific inhibitors targeting these pathways have been investigated for clinical applications and clinical trials. Some drugs already currently in clinical use for other diseases were found to be effective for lymphangioma, although the mechanisms underlying the anti-tumor effects remain unclear. Molecular classification based on molecular pathology and investigation of the molecular mechanisms of current clinical drugs is the next step toward developing more effective individualized treatment of children with lymphangioma with reduced side effects.

Peri-procedural Anticoagulation in Patients with Head and Neck Versus Extremity Venous Malformations

OBJECTIVE

(1) Review a multidisciplinary vascular anomalies center's practice regarding periprocedural anticoagulation for venous malformations (VM) and the associated risk of thromboembolic and disseminated intravascular coagulation (DIC) events. (2) Compare the risk of thromboembolic events and DIC post-procedure between head and neck (H&N) and extremity VM patients.

METHODS

An Institutional Review Board (IRB)-approved, retrospective chart review was performed on 120 VM patients. A thromboembolic event was defined as a thrombus formation post-sclerotherapy or post-surgery within 2 months in a distant or local venous structure not directly addressed by the procedure.

RESULTS

There were 39 cases involving the H&N and 81 cases based at the extremities. There were eight cases of post-procedure thrombus formation within the extremity VM group (8/71; 11.3%) as opposed to 0 cases in the H&N group (OR: 0, 95% CI .00-.09), p = .049. There was no difference in incidence of post-procedure thromboembolic events between those with elevated D-dimer (H&N: 0%, extremity: 22.7%, 5/22) and normal D-dimer values (H&N: 0%, extremity: 6.3% [1/16], P = .370). There was no difference in incidence of post-procedure thromboembolic events between those who received periprocedural anticoagulation (H&N: 0%, extremity: 21%, 4/19) and those who did not (H&N: 0%, extremity: 8.2%, 4/49), (Extremity: OR: 3.00, .67-13.50, P = .206).

CONCLUSION

Post-procedure thromboembolism is rare in the treatment of venous malformations, especially in the head and neck subsite. Regardless of anticoagulation use, there were no thromboembolic events for H&N VM patients. Such events are rare, and the odds may approach zero, especially with small sample size.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1163-1167, 2021.

Clinicoradiologic predictors of sclerotherapy response in low-flow vascular malformations

OBJECTIVE

To evaluate the clinical effectiveness of sclerotherapy agents in low-flow vascular malformations (LFVM) and identify clinical/imaging features to predict response.

METHODS

A retrospective analysis of hospital records of symptomatic LFVM patients who underwent phlebosclerotherapy from January 2015 to April 2018 was done. Patients were subdivided into venous malformations (VM) and lymphatic malformations (LM). Out of 246 cases, 223 patients (132 males, 91 females; age range, 2-52 years) had VM and 23 (13 males, 10 females; age range, 3 months to 45 years) had LM. The clinical response was graded as excellent (>60%), good (30%-60%), and poor (<30%). More than 30% was considered as acceptable response. The χ² test was performed for correlation between clinical response and clinical, sonographic, magnetic resonance imaging, phlebographic parameters followed by multilinear regression.

RESULTS

Cavitary (43%) and spongy (37.7%) were the most common phlebographic patterns seen among VM and a cavitary pattern (87%) was most frequent in LM. Sodium tetradecyl sulphate and bleomycin were most commonly used sclerosants in VM and LM, respectively. The mean number of sessions was 4.35 (range, 1-23) in VM and 2.64 (range, 2-7) in LM. Among VM, 114 patients (51.1%) had excellent response to treatment (>60%) and 75.8% patients had an acceptable response (>30%). All patients with LM had an acceptable response (excellent response in 86.9%). Clinical disfigurement, discoloration, diffuse involvement, dysplastic venous morphology on phlebogram, and late and indirect draining vein correlated with poor response to sclerotherapy in VM (P = .003, P = .036, P = .007, P = .008, P = .003, and P = .035, respectively). Cystic components on ultrasound examination and direct draining vein were seen more often in excellent responders (P = .004 and P = .007) in addition to absence of disfigurement, discoloration, and diffuse involvement (P = .032, P = .003, and P = .002). Mod els comprising clinical disfigurement, dysplastic veins, and late draining vein had the greatest predictive value for poor response (R² = 0.256). Also, the best model for predicting excellent response comprised presence of direct draining vein and absence of skin discoloration (R² = 0.109). Eleven instances of minor complications occurred among a total of 1032 sessions, seven with sodium tetradecyl sulphate and four with polidocanol.

CONCLUSIONS

Acceptable response to sclerotherapy was achieved in majority of LFVM with extremely low complication rates. Clinicoradiologic features, especially phlebographic findings, correlated with response to sclerotherapy.

Safety and effectiveness of percutaneous sclerotherapy for venous disorders of the labia majora in patients with vascular malformations

OBJECTIVE

The aim of this study was to evaluate the safety and clinical outcomes of percutaneous sclerotherapy of venous disorders of the labia majora in patients with vascular malformations of the lower limbs.

METHODS

Thirty percutaneous sclerotherapy treatments were performed over a 6-year period among 17 female patients with symptomatic venous malformation (VM) or secondary varicosis of the labia majora. Four patients were treated with sclerotherapy alone, 13 patients had additional procedures to control the VM before sclerotherapy. Polidocanol was used as sclerosant. Indications for sclerotherapy included pain, bleeding, thrombophlebitis, and swelling. Genitourinary symptoms were recorded. The number of treatments and procedure-related complications were registered. Complications were classified according to the Society of Interventional Radiology (SIR) classification system (grade A-E). The 3-month postintervention follow-up included magnetic resonance imaging, clinical examination, and a symptom-related questionnaire. If no reintervention was necessary, consultation was scheduled biannually.

RESULTS

All patients had local swelling and pain; only a fraction of the patients had further symptoms with bleeding or thrombophlebitis (47% each). Eight patients required reintervention. No major complications were observed; minor complications such as postprocedural swelling occurred in 29% (SIR grade A), pain occurred in 17% (SIR grade B), and skin blistering developed in 5% (SIR grade B). Upon follow-up examination after a median of 40 months, 76% showed complete relief of symptoms, and 23% reported partial relief. All patients reported a substantial reduction in pain (75% >5 points in visual analogue scale) and swelling (88% complete cessation).

CONCLUSIONS

Percutaneous sclerotherapy is a safe and effective treatment option of VM and secondary varicosis of the labia majora.

An institution-wide algorithm for direct-stick embolization of peripheral venous malformations

OBJECTIVE

No standardized therapeutic algorithm or embolic agent of choice has yet been identified for management of congenital peripheral venous malformations (VMs). Treatment options and reported outcomes therefore vary widely. Herein, we present an institution-wide algorithm for management of symptomatic congenital peripheral VMs using a single embolotherapeutic modality.

METHODS

During 36 months, patients with symptomatic congenital peripheral VMs underwent contrast-enhanced magnetic resonance imaging. Hematologic monitoring for localized intravascular coagulopathy was performed in all. Perioperative anticoagulation was administered accordingly. When applicable, venous duplex ultrasound was performed to assess for presence and patency of a deep venous system and superficial venous reflux. If superficial venous reflux was identified, radiofrequency ablation was performed per standard protocol before or at the time of initial embolization. Direct-stick embolizations (DSEs) were performed by a single operator using two concentrations (1% and 3%) of sodium tetradecyl sulfate (STS; Sotradecol; AngioDynamics, Latham, NY) without foam preparation. Patients were followed up clinically for resolution of symptoms, coagulopathic monitoring, and development of complications. All data were prospectively maintained and retrospectively reviewed.

RESULTS

There were 71 DSEs performed in 40 patients (1.8 procedures per patient [range, 1-8]; 12 male patients; mean age, 22 years [range, 2-53 years]). Mean follow-up was 17.1 months (range, 0.8-31.6 months). Presenting symptoms included pain (n = 40 [100%]), swelling (n = 36 [90%]), and cosmetic disfigurement (n = 32 [80%]). Anatomic distribution was upper extremity (n = 16 [23%]), lower extremity (n = 37 [52%]), head and neck (n = 7 [10%]), trunk (n = 10 [14%]), and visceral (n = 1 [1%]). There were 33 sporadic cases, 4 (10%) Klippel-Trénaunay syndrome cases, 2 (5%) blue rubber bleb nevus syndrome cases, and 1 (2.5%) CLOVES (congenital lipomatous overgrowth, vascular malformations, epidermal nevus, and skeletal deformities) syndrome case. Four patients presented with localized intravascular coagulopathy, two of whom required perioperative enoxaparin. Twenty-six patients (65%) required a single DSE session with complete symptom relief. Fourteen patients (35%) required repeated DSE. Two patients (5%) required adjunctive surgical excision. There was one postoperative death (1.4%) secondary to massive pulmonary embolism. Complications were otherwise limited to skin necrosis (n = 2 [3%]). Mean volume of sclerosant per session was 7 mL of 1% STS (range, 3-14 mL), and 15 mL of 3% STS (range, 3-42.5 mL).

CONCLUSIONS

In the absence of allergic reactions, most congenital peripheral VMs can be safely embolized with liquid STS, thereby avoiding the well-documented toxicity of ethanol. Venous thromboembolism remains a major source of morbidity and mortality in this population of patients despite close hematologic scrutiny. Prospective randomized trials are needed for embolotherapeutic standardization.

Use of an intravenous sclerosing foam (3% sodium tetradecyl sulfate) for treatment of orbital varix in a dog

A 6-month-old intact male Standard Dachshund was referred for evaluation of a soft tissue swelling above the right eye. Examination of the right eye revealed mild lateral deviation of the globe, normal vision, and a dorsonasal soft tissue swelling. Examination of the posterior segment was normal. Dual-phase computed tomography angiography was consistent with an orbital varix of the angularis oculi and right dorsal external ophthalmic veins with no evidence of arterial involvement. Treatment involved fluoroscopically guided coil embolization of the venous outflow with nine platinum microcoils, followed by sclerotherapy of the varix using 1.5 mL of 3% sodium tetradecyl sulfate foam. Moderate-to-marked swelling was noted at the treatment site in the weeks following therapy, which gradually resolved. At final reexamination 3 months post-therapy, complete sclerosis and resolution of the orbital varix were documented. To the authors' knowledge, this is the first reported case involving the use of a sclerotic agent for successful treatment of a venous malformation in a dog.

Venous malformations of the head and neck: current concepts in management

Low-flow venous malformations are congenital lesions and they are the third most common vascular anomaly in the head and neck. In this paper, the third in a series of three educational reviews, we discuss current trends in their management, and include a summary of common sclerosant agents used in their control.

Outcome of Management of Vascular Malformations of Lip

OBJECTIVES

To describe the characteristics and outcome of management of vascular malformations of lip.

PLACE AND DURATION OF STUDY

The Department of Plastic Surgery and Burn Unit, King Edward Medical University, Mayo Hospital, Lahore, from January 2009 to December 2013.

METHODS

A prospective case series of 38 patients with vascular malformation of lip was performed. Demographic information and clinical features were noted. Treatment employed, complications, functional, and cosmetic outcome were recorded. Surgical debulking was performed as definitive treatment in all patients and nonsurgical techniques were added as adjuvant modalities in 18 patients. Sclerotherapy was performed for venous malformations in 10 patients. LASER was performed in 8 patients with capillary or combined malformations. Arterial malformations were managed surgically without embolization. Postexcision defects were closed primarily in 36 patients with Abbe flap in 1 and nasolabial flap in another patient for reconstruction.

RESULTS

Of 38 patients included in the study 20 (53%) were males with mean (SD) age 18 (6) years. Twenty-one percent were high and 79% low-flow malformations (29% venous, 16% capillary, and 34% combined). Lower lip was involved in 70% patients with 95% having difficulty in eating and 87% abnormal speech. Referring diagnosis was incorrect in 35% patients. Postsclerotherapy and postexcision pain scores were mean (SD) 5 (1.26) and 4 (1) respectively. All patients had improvement in eating and speech with restoration of normal muscle function in mean (SD) 5.63 (1.2) weeks. Ninety-five percent patients were satisfied with their outlook. One patient had recurrence at 1 year follow-up.

CONCLUSION

Surgical debulking with proper use of adjuvant procedure for vascular malformations of lip produces best functional and aesthetic results with minimal complications.

Efficacy of doxycycline and sodium tetradecyl sulfate sclerotherapy in pediatric head and neck lymphatic malformations

OBJECTIVES

Lymphatic malformations are congenital vascular anomalies that occur from abnormal development of the lymphatic channels. Studies have shown that sclerotherapy can be a reliable alternative to surgery. The purpose of this retrospective study is to evaluate the safety and efficacy of percutaneous sclerotherapy with doxycycline and 3% Sotradecol as primary treatment for pediatric head and neck LMs, and to assess outcomes based on lesion classification, location and sclerosant used.

STUDY DESIGN

This study was a single center, retrospective, case series study.

MATERIALS AND METHODS

The medical records of 38 children who underwent percutaneous sclerotherapy of LMs in the head and neck region at our tertiary care center between 1/1/2006 and 1/31/2011 were reviewed. A mean average of 2.9 (range 1-10) sclerotherapy sessions per child were performed. LMs involved primarily the face (61.3%), posterior neck (48.4%), submental area (45.2%), and anterior neck (35.5%).

RESULTS

Twenty-nine subjects had adequate follow-up data, with 51.7% demonstrating complete resolution, 27.6% moderate improvement, and 20.7% no response. There was no significant difference in the outcome based on the sclerosant agent used or location of the lesion. Lesion type did affect outcome and macrocystic lesions were found to have a significantly higher resolution rate (95.2%) than microcystic or mixed lesions (p < 0.05). The total number of complications was similar between agents and all were minor.

CONCLUSION

Our results indicate that percutaneous therapy with doxycycline and Sotradecol is safe and effective for children with LMs of the head and neck. Better outcomes were observed with macrocystic LMs.

LEVEL OF EVIDENCE

4.

Comparison of sonographically guided percutaneous sodium tetradecyl sulfate injection with ethanol injection in the treatment of benign nonfunctioning thyroid nodules

PURPOSE

To compare the efficacy of percutaneous sodium tetradecyl sulfate (STS) injection with ethanol injection in the treatment of benign nonfunctioning thyroid nodules.

MATERIALS AND METHODS

This prospective study included 47 patients with 50 benign thyroid nodules. The lesions were randomly assigned into two groups: 20 in the ethanol arm and 30 in the STS arm. The mean lesion volume was 25.6 mL ± 28.5 (range, 4-122.1 mL) in the ethanol arm and 25.4 mL ± 27 (range, 0.72-129 mL) in the STS arm. One sitting of sclerosant injection was done in 20 lesions, and two injections, three injections, four injections, five injections, six injections, seven injections, and eight sittings of injections were done in 9 lesions, 4 lesions, 8 lesions, 4 lesions, 2 lesions, 2 lesions, and 1 lesion. The mean volumes of the instilled ethanol and STS were 5.3 mL and 7.8 mL, respectively, per sitting. Follow-up sonography was performed at 1, 3, 6, and 12 months after the procedure.

RESULTS

The final 12-month follow-up lesion volumes were 4.1 mL ± 3.7 (range, 0.3-15.2 mL) in the ethanol group and 4.4 mL ± 5.8 (range, 0.01-29.6 mL) in the STS group (P = .85). The mean volume reduction was 84% and 82.8% in the two groups. No significant adverse effects were seen in either of the two groups.

CONCLUSIONS

Sonographically guided percutaneous ethanol and STS injections are not significantly different from each other in terms of the volume reduction achieved in benign nonfunctioning thyroid nodules.

A clinical update and radiologic review of pediatric orbital and ocular tumors

While pediatric orbital tumors are most often managed in tertiary care centers, clinicians should be aware of the signs of intraocular and orbital neoplasms. In the pediatric population, a delay in diagnosis of orbital and intraocular lesions, even if benign, can lead to vision loss and deformity. Intraocular lesions reviewed are retinoblastoma, medulloepithelioma, and retinal astrocytic hamartoma. Orbital neoplasms reviewed are rhabdomyosarcoma, neuroblastoma metastases, optic pathway glioma, plexiform neurofibroma, leukemia, lymphoprolipherative disease, orbital inflammatory syndrome, dermoid and epidermoid inclusion cysts, and Langerhans' cell histiocytosis. Vascular lesions reviewed are infantile hemangioma and venous lymphatic malformation. In conjunction with clinical examination, high-resolution ophthalmic imaging and radiologic imaging play an important role in making a diagnosis and differentiating between benign and likely malignant processes. The radiologic imaging characteristics of these lesions will be discussed to facilitate prompt diagnosis and treatment. The current treatment modalities and management of tumors will also be reviewed.