1
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Crary SE, Mack JM. Anticoagulation and vascular anomalies. Res Pract Thromb Haemost 2024; 8:102402. [PMID: 38694837 PMCID: PMC11060946 DOI: 10.1016/j.rpth.2024.102402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 05/04/2024] Open
Abstract
A State of the Art lecture titled "Anticoagulation and Vascular Anomalies" was presented at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2023. Vascular anomalies have been classified by the International Society for the Study of Vascular Anomalies into vascular tumors and vascular malformations. Although some vascular tumors, such as tufted angioma and kaposiform hemangioendothelioma, and other vascular malformations can present with coagulation aberrancies, these are not generally managed with anticoagulation. A subclassification of vascular malformations includes slow-flow vascular malformations. It is this subgroup specifically that has a high risk of venous thromboembolism (VTE) and morbidity associated with coagulopathy that may be present. In these select cases, anticoagulation may be indicated to reduce the risk of VTE, treat VTE, or manage localized thrombosis in the malformation that causes significant pain and reduced quality of life. There are established risk factors for VTE in these patients that will be reviewed. Finally, we summarize relevant new data on this topic presented during the 2023 ISTH Congress.
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Affiliation(s)
- Shelley E. Crary
- Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
| | - Joana M. Mack
- Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
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2
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Gatts J, Chandra SR, Ricci K. Medical Management and Therapeutic Updates on Vascular Anomalies of the Head and Neck: Part 2. Oral Maxillofac Surg Clin North Am 2024; 36:115-123. [PMID: 37981343 DOI: 10.1016/j.coms.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Discovery of inherited and somatic genetic mutations, along with advancements in clinical and scientific research, has improved understanding of vascular anomalies and changed the treatment paradigm. With aim of minimizing need for invasive procedures and improving disease outcomes, molecularly targeted medications and anti-angiogenesis agents have become important as both adjuncts to surgery, and increasingly, as the primary treatment of vascular anomalies. This article highlights the commonly used and emerging therapeutic medications for non-malignant vascular tumors and vascular malformations in addition to medical management of associated hematologic abnormalities.
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Affiliation(s)
- Jorie Gatts
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Srinivasa R Chandra
- Department of Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA.
| | - Kiersten Ricci
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA
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3
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Villarreal EG, Gonzalez-Moctezuma K, Rodríguez-Mendoza DI, Jiménez-Antolínez YV, Ramos-Gómez LI, Ortega Alonzo SE. Kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon successfully treated with sirolimus: A case report and literature review on pharmacological treatment. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2022. [DOI: 10.1016/j.phoj.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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4
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Kumar S, Gunjan K, Priyadarshi RN, Mahto M. Multiorgan Visceral Hemangiomas Presenting with Sequential Ruptures and Hemorrhage, Cardiac Thrombus, and Thromboembolic Phenomenon. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2022. [DOI: 10.1055/s-0042-1751252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
AbstractVascular anomalies can be seen in a disseminated or diffuse state to involve multiple superficial and deep sites. Large and diffuse lesions are known to induce a hemorrhagic tendency. The authors present, which they believe is the first case of multiorgan hemangiomas with rupture at multiple sites, along with hitherto unreported cardiac thrombus, with arterial and venous thromboembolic events, ultimately ending with the patient's demise.
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Affiliation(s)
- Subhash Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences Patna, Patna, Bihar, India
| | - Kamlesh Gunjan
- Department of Urology, All India Institute of Medical Sciences Patna, Patna, Bihar, India
| | - Rajeev N. Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences Patna, Patna, Bihar, India
| | - Mala Mahto
- Department of Biochemistry, All India Institute of Medical Sciences Patna, Patna, Bihar, India
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5
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Pahl KS, Pabon-Ramos WM, Jeng MR. How we approach localized vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29321. [PMID: 36070210 DOI: 10.1002/pbc.29321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 01/19/2023]
Abstract
Vascular anomalies are a group of disorders divided into two distinct subtypes: vascular tumors and vascular malformations. Vascular tumors are proliferative in nature, while malformations are nonproliferative. Simple, localized vascular malformations refer to a group of malformations that are localized to a single area of involvement. These simple malformations include capillary, lymphatic, venous, and arteriovenous malformations. The pediatric hematologists and oncologists are becoming increasingly involved in the diagnosis and management of these disorders. This review presents four cases as a means to discuss the diagnosis, clinical and imaging features, and management strategies of simple, localized vascular malformations.
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Affiliation(s)
- Kristy S Pahl
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Waleska M Pabon-Ramos
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael R Jeng
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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6
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Ricci KW, Iacobas I. How we approach the diagnosis and management of complex lymphatic anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e28985. [PMID: 33844431 DOI: 10.1002/pbc.28985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/29/2021] [Accepted: 02/13/2021] [Indexed: 12/26/2022]
Abstract
Complex lymphatic anomalies (CLA) are congenital diseases of the lymphatic circulation system that are associated with significant morbidity and early mortality. While guidelines for the comprehensive evaluation of the CLA were recently published, the diagnostic approach and medical management are not standardized. This article presents the clinical features of four CLA: Gorham-Stout disease, generalized lymphatic anomaly, kaposiform lymphangiomatosis, and central collecting lymphatic anomaly. We also offer three cases from the authors' practice and our views on diagnostic testing and disease management including supportive care, medical therapies, and other interventions.
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Affiliation(s)
- Kiersten W Ricci
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Hematology and Hemangioma and Vascular Malformation Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ionela Iacobas
- Department of Pediatrics, Baylor College of Medicine, Vascular Anomalies Center at Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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7
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Schmidt VF, Olivieri M, Häberle B, Masthoff M, Deniz S, Sporns PB, Wohlgemuth WA, Wildgruber M. Interventional Treatment Options in Children with Extracranial Vascular Malformations. Hamostaseologie 2022; 42:131-141. [PMID: 35263769 DOI: 10.1055/a-1728-5686] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Extracranial vascular malformations vary greatly and belong to the complex field of orphan diseases and can involve all segments of the vascular tree: arteries, capillaries, and veins, and similarly the lymphatic system. The classification according to the International Society for the Study of Vascular Anomalies (ISSVA) represents an important guidance for selecting appropriate therapy. Although many of the principles of endovascular treatment, including image-guided sclerotherapy and embolization, are similar in adult and pediatric practice, there are some distinct differences regarding the treatment of vascular malformations of children. Thus, it is crucial to involve longer-term plan about managing these chronic diseases and their impact on a growing child. This review provides a detailed overview over the clinical presentation of venous, lymphatic, and arteriovenous malformations in children and emphasizes the specifics of their interventional treatment options, including distinct pediatric dose limitations and procedure-related side effects.
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Affiliation(s)
- Vanessa F Schmidt
- Department of Radiology, Ludwig Maximilian University Hospital, Munich, München, Germany
| | - Martin Olivieri
- Paediatric Thrombosis and Haemostasis Unit, Dr. von Hauner Children's Hospital Munich, Ludwig Maximilian University, Munich, Germany
| | - Beate Häberle
- Department for Pediatric Surgery, Ludwig Maximilian University Hospital, Munich, München, Germany
| | - Max Masthoff
- Clinic of Radiology, University Hospital Muenster, Muenster, Germany
| | - Sinan Deniz
- Department of Radiology, Ludwig Maximilian University Hospital, Munich, München, Germany
| | - Peter B Sporns
- Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg - Eppendorf, Hamburg, Germany
| | - Walter A Wohlgemuth
- Clinic and Policlinic of Diagnostic Radiology, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Moritz Wildgruber
- Department of Radiology, Ludwig Maximilian University Hospital, Munich, München, Germany
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Pati S, Das MK, Rana A, Das E, Sarkar S, Sherpa N, Datta S. Kaposiform Hemangioendothelioma with Kasabach-Merritt Phenomenon. Indian J Pediatr 2021; 88:1142-1144. [PMID: 34106442 DOI: 10.1007/s12098-021-03817-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
A 3-y-3-mo old male child presented with massive hypertrophy and bluish-purple discoloration of the left upper limb and adjacent chest wall of 3 mo duration. There was no h/o fever, weight loss, painful large joint swelling, or any bleeding manifestations. He had spindle like nonprogressive, painless swelling of all fingers of the left hand since infancy. The child was moribund with microangiopathic hemolytic anemia, thrombocytopenia, and consumptive coagulopathy without sepsis. He received multiple transfusions of fresh frozen plasma (FFP), platelets, and packed RBC. Paradoxical worsening of symptoms with platelet transfusions and radiological evidences led to the diagnosis of a very rare congenital multifocal vascular tumor, kaposiform hemangioendothelioma (KHE) with Kasabach-Merritt phenomenon (KMP). The index case of KHE was multifocal with cutaneous lesions, osteolytic bony lesions of all phalanx and metacarpals of the left hand, and intrathoracic extension. It was successfully managed with a combination of steroid, vincristine and sirolimus.
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Affiliation(s)
- Sananda Pati
- Department of Pediatric Medicine, IPGME&R and SSKM Hospital, 244, A.J.C. Bose Road, Kolkata, West Bengal, 700020, India.
| | - Mrinal Kanti Das
- Department of Pediatric Medicine, IPGME&R and SSKM Hospital, 244, A.J.C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Akshay Rana
- Department of Pediatric Medicine, IPGME&R and SSKM Hospital, 244, A.J.C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Emilee Das
- Department of Pediatric Medicine, IPGME&R and SSKM Hospital, 244, A.J.C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Soumyadeep Sarkar
- Department of Pediatric Medicine, IPGME&R and SSKM Hospital, 244, A.J.C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Norbu Sherpa
- Department of Pediatric Medicine, IPGME&R and SSKM Hospital, 244, A.J.C. Bose Road, Kolkata, West Bengal, 700020, India
| | - Supratim Datta
- Department of Pediatric Medicine, IPGME&R and SSKM Hospital, 244, A.J.C. Bose Road, Kolkata, West Bengal, 700020, India
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9
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Venous Malformations and Blood Coagulation in Children. CHILDREN-BASEL 2021; 8:children8040312. [PMID: 33924092 PMCID: PMC8074292 DOI: 10.3390/children8040312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
Introduction: Venous malformations (VMs) are congenital low-flow lesions with a wide spectrum of clinical manifestations. An increasing number of studies link VMs to coagulation abnormalities, especially to elevated D-dimer and decreased fibrinogen. This condition, termed localized intravascular coagulopathy (LIC), may pose a risk for hemostatic complications. However, detailed data on the laboratory variables for coagulation and fibrinolytic activity in VM patients are limited. We addressed this question by systematically analyzing the coagulation parameters in pediatric VM patients. Methods: We included 62 patients (median age 11.9 years) with detailed laboratory tests for coagulation and fibrinolytic activity at a clinically steady phase. We assessed clinical and imaging features of VMs and their correlations with coagulation and fibrinolysis variables using patient records and MRI. Results: D-dimer was elevated in 39% and FXIII decreased in 20% of the patients, as a sign of LIC. Elevated D-dimer and decreased FXIII were associated with large size, deep location, and diffuse and multifocal VMs. FVIII was elevated in 17% of the patients and was associated with small VM size, superficial and confined location, discrete morphology, and less pain. Surprisingly, antithrombin was elevated in 55% of the patients but without associations with clinical or other laboratory variables. Conclusions: LIC was common in pediatric patients with VMs. Our results provide a basis for when evaluating the risks of hemostatic complications in children with VMs. Further research is warranted to explore the mechanisms behind coagulation disturbances and their relation to clinical complications.
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10
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Kemp MT, Obi AT, Henke PK, Wakefield TW. A narrative review on the epidemiology, prevention, and treatment of venous thromboembolic events in the context of chronic venous disease. J Vasc Surg Venous Lymphat Disord 2021; 9:1557-1567. [PMID: 33866055 DOI: 10.1016/j.jvsv.2021.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/28/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Chronic venous disease (CVD) describes a spectrum of conditions associated with venous hypertension. The association between various CVD etiologies and the subsequent risk of venous thromboembolism (VTE), such as deep vein thrombosis or pulmonary embolism, is a topic of considerable clinical interest. The aims of the present review were to characterize the risk of VTE according to the CVD etiology and to determine the optimal anticoagulation strategy for the treatment or prevention of VTE in patients with CVD. METHODS An extensive search of the available surgical and medical data was conducted in PubMed and Google Scholar. We searched for the following terms and other related terms to identify relevant studies: CVD, chronic venous insufficiency, varicose veins, post-thrombotic syndrome (PTS), anticoagulation, venous thromboembolism, and venous disease scoring systems (eg, CEAP [clinical, etiology, anatomic, pathophysiology], Villalta, Ginsberg, venous clinical severity score). The identified studies included randomized control trials, retrospective and prospective observational studies, narrative and systematic reviews, case reports, and case series that contributed to the proposed aims. The ClinicalTrials.gov database was also queried to identify any relevant ongoing clinical trials. RESULTS Congenital CVD carries a heightened risk of VTE, although few higher level studies are available to inform on this topic or on the appropriate anticoagulation strategies for these patients. Noncongenital CVD seems to carry a heightened risk of VTE, although few studies have adequately differentiated between primary and secondary etiologies. Varicose veins are a risk factor for primary VTE but might not be associated with an increased risk of recurrent VTE. In the hospital setting, patients with varicosities should be provided thromboprophylaxis. In the setting of varicose vein intervention, high-risk patients should be identified using risk assessment models and receive thromboprophylaxis. The risk of recurrent VTE in the setting of PTS is unclear but indefinite anticoagulation is not currently indicated. For patients with PTS, residual vein thrombosis might be an indicator of when anticoagulation can be safely stopped, although practical limitations to its application exist. CONCLUSIONS CVD is associated with an increased risk of VTE. Few studies have differentiated between classes of CVD using a standardized method and have assessed the efficacy of anticoagulation prophylaxis against or treatment of VTE. Additional studies are needed to determine the optimal therapy for preventing and treating VTE in patients with active concurrent CVD.
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Affiliation(s)
- Michael T Kemp
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
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11
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Budge EJ, Khalil Allam MA, Mechie I, Scully M, Agu O, Lim CS. Venous malformations: Coagulopathy control and treatment methods. Phlebology 2020; 36:361-374. [PMID: 33283636 DOI: 10.1177/0268355520972918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous malformations (VMs) are ectatic channels which arise as a result of vascular dysmorphogenesis, commonly caused by activating mutations in the endothelial tyrosine kinase receptor (TIE2)/phosphatidylinositol 3-kinase (PI3Kinase) pathway. With a prevalence of 1% in the general population, and a diverse clinical presentation depending on site, size and tissue involvement, their treatment requires a personalised and multidisciplinary approach. Larger lesions are complicated by local intravascular coagulopathy (LIC) causing haemorrhagic and/or thrombotic complications which can progress to disseminated intravascular coagulopathy (DIC). METHODS We performed a literature review using a PubMed® search and identified 15 articles to include. References of these texts were examined to further expand the literature review.Principle findings: Several treatment options have been explored, including compression, sclerotherapy, laser therapy, cryoablation and surgery in addition to the management of LIC with low-molecular-weight-heparin (LMWH) and other anticoagulants. Targeted molecular therapies acting on the phosphatidylinositol 3-kinase (PI3Kinase)/Protein Kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway are newly emerging. CONCLUSION Despite a wealth of literature, larger, multi-centric, randomised and prospective trails are required to offer further clarification on the therapeutic management of coagulopathy control and to provide symptomatic benefit to patients with VMs. There should be efforts to provide long term follow up and to use standardised risk stratification tools and quality of life (QOL) questionnaires to aid comparison of agents and treatment protocols.
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Affiliation(s)
- Eleanor J Budge
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | | | - Imogen Mechie
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Marie Scully
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK.,Research Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - Obi Agu
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK.,Research Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - Chung Sim Lim
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK.,Research Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
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12
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Abstract
Vascular anomalies, comprised of vascular tumors and malformations, are frequently associated with coagulopathy. Recognition of and familiarity with these vascular anomaly-associated hematologic abnormalities prior to surgery or interventional procedures is essential for pre-operative pre-operative planning. Complicated coagulopathies present within the framework of either Kasabach-Merritt phenomenon (KMP) or localized intravascular coagulopathy (LIC), and their management benefits from the expertise of a hematologist for optimal intra- and peri‑operative care. Furthermore, with the recent broadening of understanding of vascular anomalies and the addition of new classification sub-groups, distinctions of these two classic coagulopathy phenotypes have been recognized. This review summarizes the main features of these coagulopathies, described according to their vascular anomaly type, highlighting clinical aspects relevant to surgical management.
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Affiliation(s)
- Kiersten W Ricci
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7015, Cincinnati 45229, OH, United States.
| | - Leonardo R Brandão
- The Hospital for Sick Children, Division of Haematology-Oncology, Toronto, Ontario, Canada
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13
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Ricci KW, Chute C, Hammill AM, Dasgupta R, Patel M. Retrospective study of hematologic complications in patients with slow-flow vascular malformations undergoing sclerotherapy. Pediatr Blood Cancer 2020; 67:e28277. [PMID: 32779831 DOI: 10.1002/pbc.28277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/07/2020] [Accepted: 03/05/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Slow-flow vascular malformations (SFVM) are associated with localized intravascular coagulopathy (LIC), which is characterized by elevated D-dimer and, when severe, hypofibrinogenemia. LIC results in intralesional clotting and hemorrhage and increases risk for significant thrombotic and bleeding complications. Sclerotherapy has been a suggested potential trigger for LIC worsening to disseminated intravascular coagulopathy. Hematologic complications of sclerotherapy in SFVM, along with low-molecular-weight heparin (LMWH) used to prevent worsening LIC, are largely unstudied. PROCEDURE Medical records of patients with SFVM and LIC who underwent sclerotherapy at Cincinnati Children's Hospital Medical Center from July 2008 to December 2016 were reviewed for periprocedural hematologic complications. LMWH dose, frequency, and course length were evaluated. RESULTS Fifty-nine patients with SFVM and LIC underwent 281 sclerotherapy procedures, of which 86% were in children. Eighty-five percent of patients received periprocedural LMWH, although at various doses and course lengths. No thrombotic complications occurred in children. One adult on LMWH developed pulmonary emboli after sclerotherapy. No major bleeding complications occurred postoperatively. In four patients, fibrinogen dropped below 100 mg/dL post-sclerotherapy, requiring cryoprecipitate. One patient required packed red blood cell (RBC) transfusion for sclerotherapy-induced hemolysis. No intraoperative bleeding or thrombotic events occurred. CONCLUSION LMWH use, at subtherapeutic dosing, was common in this patient population and did not appear to increase risk of significant bleeding before, during, or after sclerotherapy. In children with SFVM, bleeding and thrombotic complications after sclerotherapy appear rare. Although safe, prospective studies are needed to evaluate the efficacy of LMWH to prevent worsening coagulopathy with procedures.
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Affiliation(s)
- Kiersten W Ricci
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carol Chute
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adrienne M Hammill
- Hemangioma and Vascular Malformation Center, Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Roshni Dasgupta
- Hemangioma and Vascular Malformation Center, Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Manish Patel
- Hemangioma and Vascular Malformation Center, Division of Interventional Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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14
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Han YY, Sun LM, Yuan SM. Localized intravascular coagulation in venous malformations: A system review. Phlebology 2020; 36:38-42. [PMID: 32731789 DOI: 10.1177/0268355520946211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Venous malformation is one of the slow-flow vascular malformations. Dysfunction of coagulation often occurs in most venous malformations, especially the diffuse and multifocal lesions, referred to as localized intravascular coagulopathy. It is characterized by the elevation of D-dimers and fibrin degradation products, low levels of fibrinogen, FV, FVIII, FXIII, and antithrombin III, and sometimes minor-to-moderate thrombocytopenia. Here we reviewed the clinical manifestations, pathogenesis, diagnosis, and treatment of localized intravascular coagulopathy in venous malformations.
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Affiliation(s)
- Yu-Yu Han
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China
| | - Li-Ming Sun
- Department of Plastic Surgery, Jinling Hospital, Nanjing, School of Clinical Medicine, Bengbu Medical College, Jiangsu, China
| | - Si-Ming Yuan
- Department of Plastic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China
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15
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Cashell J, Smink GM, Helm K, Xavier F. Kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon in an infant: Successful treatment with prednisolone, vincristine, and addition of sirolimus. Pediatr Blood Cancer 2018; 65:e27305. [PMID: 30070028 DOI: 10.1002/pbc.27305] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/21/2018] [Accepted: 06/07/2018] [Indexed: 12/30/2022]
Abstract
A full-term newborn with kaposiform hemangioendothelioma (KHE) affecting the right thigh with thrombocytopenia due to Kasabach-Merritt phenomenon (KMP) was referred to our center. After biopsy, he rapidly evolved to severe thrombocytopenia and severe coagulopathy. Standard therapy was initiated with prednisolone and vincristine. His coagulopathy worsened to life-threatening hemorrhage necessitating aggressive blood products replacement. Sirolimus was added; he became transfusion independent with no further bleeding and reduction in tumor size. Addition of sirolimus to treatment of vascular anomalies with hemostatic complications should be considered as part of early treatment for patients with KMP/KHE.
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Affiliation(s)
- Jamie Cashell
- Department of Pediatric Hematology/Oncology, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Gayle M Smink
- Department of Pediatric Hematology/Oncology, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Klaus Helm
- Department of Pathology, Penn State Health, Hershey, Pennsylvania
| | - Frederico Xavier
- Department of Pediatric Hematology/Oncology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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16
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Abstract
Vascular tumors are benign neoplasms, which result from proliferating endothelial cells. These lesions present during infancy or childhood, may affect any location, and exhibit postnatal growth. Local complications include bleeding, tissue destruction, and pain whereas systemic sequelae include thrombocytopenia, congestive heart failure, and death. Vascular tumors should be differentiated from vascular malformations, which present at birth, have a quiescent endothelium, and grow in proportion to the child. Together, vascular tumors and malformations comprise the field of vascular anomalies.
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Affiliation(s)
- Jeremy A Goss
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue Boston, MA, 02115, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue Boston, MA, 02115, USA.
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Nakano TA, Zeinati C. Venous Thromboembolism in Pediatric Vascular Anomalies. Front Pediatr 2017; 5:158. [PMID: 28791278 PMCID: PMC5522837 DOI: 10.3389/fped.2017.00158] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/30/2017] [Indexed: 01/19/2023] Open
Abstract
The presence of a vascular anomaly suggests that capillaries, veins, arteries, and/or lymphatic vessels have demonstrated abnormal development and growth. Often dilated and misshaped, these vessels augment normal flow of blood and lymphatic fluids that increases the overall risk to develop intralesional thrombosis. Abnormal endothelial and lymphoendothelial cells activate hemostasis and hyperfibrinolytic pathways through poorly understood mechanisms, which contribute to the development of localized intravascular coagulopathy. Vascular malformations, tumors, and complex combined syndromes demonstrate varying degrees of prothrombotic activity and consumptive coagulopathy depending on the vessels involved and the pattern and extent of abnormal growth. The clinical impact of venous thromboembolism in pediatric vascular anomalies varies from painful syndromes that disrupt quality of life to life-threatening embolic disease. There remains little literature on the study, evaluation, and treatment of thrombosis in pediatric vascular anomalies. However, there have been great advances in our ability to image complex lesions, to surgically and interventionally augment disease, and to provide enhanced supportive care including patient education, compression therapy, and strategic use of anticoagulation.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Denver, CO, United States
| | - Chadi Zeinati
- Vascular Anomalies Center, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
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18
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Liu XH, Li JY, Qu XH, Yan WL, Zhang L, Yang C, Zheng JW. Treatment of kaposiform hemangioendothelioma and tufted angioma. Int J Cancer 2016; 139:1658-66. [PMID: 27252149 DOI: 10.1002/ijc.30216] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 05/22/2016] [Accepted: 05/25/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Xiao Han Liu
- College of Stomatology; Shanghai Jiao Tong University School of Medicine; Shanghai China
- Department of Oral Surgery and Department of Oral-Maxillofacial Head and Neck Surgery; Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology; Shanghai China
| | | | - Xin Hua Qu
- Key Laboratory of Orthopedic Implant; Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai China
| | - Wei Li Yan
- Pudong Institute of Preventive Medicine; Fudan University; Shanghai China
| | - Ling Zhang
- Department of Oral Surgery and Department of Oral-Maxillofacial Head and Neck Surgery; Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology; Shanghai China
| | - Chi Yang
- Department of Oral Surgery and Department of Oral-Maxillofacial Head and Neck Surgery; Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology; Shanghai China
| | - Jia Wei Zheng
- College of Stomatology; Shanghai Jiao Tong University School of Medicine; Shanghai China
- Department of Oral Surgery and Department of Oral-Maxillofacial Head and Neck Surgery; Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology; Shanghai China
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19
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Common procedures and strategies for anaesthesia in interventional radiology. Curr Opin Anaesthesiol 2015; 28:458-63. [DOI: 10.1097/aco.0000000000000208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Fernandes VM, Fargo JH, Saini S, Guerrera MF, Marcus L, Luchtman-Jones L, Adams D, Meier ER. Kaposiform lymphangiomatosis: unifying features of a heterogeneous disorder. Pediatr Blood Cancer 2015; 62:901-4. [PMID: 25307772 DOI: 10.1002/pbc.25278] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 08/26/2014] [Indexed: 11/08/2022]
Abstract
Kaposiform lymphangiomatosis (KLA) is a rare proliferation of abnormal lymphatic vessels often complicated by pleural/pericardial effusions and a consumptive coagulopathy that may lead to life threatening hemorrhage. Establishing the diagnosis is challenging due to the clinical heterogeneity and variable findings in laboratory values, radiographic features, and pathologic characteristics. We report three patients who had slowly progressive symptoms and presented with pleural or pericardial effusions, evidence of a consumptive coagulopathy and anemia. Despite being a rare and challenging diagnosis, KLA should be considered in patients presenting with non-specific indolent symptoms, pleural or pericardial effusions and laboratory evidence of a consumptive coagulopathy.
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Affiliation(s)
- Violet M Fernandes
- Center for Cancer and Blood Disorders, Children's National Health System, Washington, District of Columbia; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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21
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Abstract
Patients with vascular anomalies present specific and unique challenges to providers of their postoperative care. Vascular anomalies can range from localized solitary lesions to diffuse lesions with vessel malformations and associated soft tissue, muscle, organ, and bone involvement. Perioperative issues for these patients can be complicated and include coagulopathies requiring anticoagulation, the need for postoperative surgical drains and specialized wound care, and the use of compression garments to maintain the desired postoperative result. This article will address these specific concerns for patients with vascular anomalies in order to create a framework for consistent and appropriate perioperative care.
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Affiliation(s)
- Carol Chute
- Hemangioma and Vascular Malformations Center, Cincinnati Children׳s Hospital Medical Center, MLC 2023, 3333 Burnet Avenue, Cincinnati, Ohio 45229.
| | - Beth Stein
- Division of Home Care Services, Cincinnati Children׳s Medical Center, Cincinnati, Ohio
| | - Mary Beth Sylvia
- Vascular Anomalies Center, Boston Children׳s Hospital, Boston, Massachusetts
| | - Erin Spera
- Vascular Anomalies Center, Boston Children׳s Hospital, Boston, Massachusetts
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22
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Abstract
Vascular anomalies (VAs) comprise a large variety of individual diagnoses that in different phases of treatment require a diverse number of medical specialists to provide optimal care. Medical therapies include agents usually associated with cancer chemotherapy, such as vincristine, as well more immunomodulatory types of drugs, such as glucocorticoids and sirolimus. These immunomodulating drugs are being successfully applied in cases that are typically categorized as vascular tumors, including kaposiform hemangioendothelioma (KHE) and tufted angioma (TA), as well as some of the more invasive types of vascular malformations (i.e., microcystic lymphatic malformations and blue rubber bleb nevus syndrome (BRBNS). These therapies need to be combined with good supportive care, which often involves anticoagulation, antimicrobial prophylaxis, and comprehensive pain and symptom-relief strategies, as well as appropriate drug monitoring and management of side effects of medical treatment. The optimal care of these patients frequently involves close collaboration between surgeons, interventional and conventional radiologists, medical subspecialists, and nurses.
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Affiliation(s)
- Judith F Margolin
- Baylor College of Medicine, Texas Children's Cancer and Hematology Service, Houston, Texas
| | - Heather Mills Soni
- Baylor College of Medicine, Texas Children's Cancer and Hematology Service, Houston, Texas
| | - Sheena Pimpalwar
- Division of Interventional Radiology, Department of Radiology, TCH, Baylor College of Medicine, Houston, Texas
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23
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Theiler M, Wälchli R, Weibel L. Vascular anomalies - a practical approach. J Dtsch Dermatol Ges 2013; 11:397-405. [PMID: 23464752 DOI: 10.1111/ddg.12046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 01/02/2013] [Indexed: 12/29/2022]
Abstract
Vascular anomalies are common clinical problems (around 4.5% of all patients) in pediatric dermatology. A correct diagnosis is possible on clinical grounds in around 90% of cases; the remaining patients may require radiologic evaluations (duplex ultrasonography, MRI scan) and, rarely, histology. Vascular anomalies are divided into tumors and vascular malformations. This clear division reflects the different biological behaviors of these two groups. The infantile hemangioma represents by far the most common vascular tumor and is characterized by a typical growth cycle consisting of rapid proliferation, plateau phase, and finally slow regression. The discovery in 2008 of the efficacy of beta blockers in this disease is a therapeutic milestone. Vascular malformations can affect all types of vessels (capillaries, veins, arteries and lymphatic vessels). They usually manifest at birth and grow proportionally with the affected child. Some show marked progression especially during puberty. Considerable progress has been made with innovative interventional therapies in recent years, but surgery remains an important option. Basic knowledge of these diseases is important to every dermatologist in order to be able to counsel and manage affected patients correctly.
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Affiliation(s)
- Martin Theiler
- Pediatric and Adolescent Dermatology, University Children's Hospital of Zurich, Switzerland; Department of Dermatology, University Hospital Zurich, Switzerland
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Blei F. Literature Watch. Lymphat Res Biol 2011. [DOI: 10.1089/lrb.2011.9103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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