Management of venous malformations

Impact of puberty on procedure frequency for treatment of simple head and neck lymphatic and venous malformations

OBJECTIVE

Puberty has been shown to accelerate growth of vascular malformations, including lymphatic (LM) and venous malformations (VM). This study aims to compare the number of procedures performed before and after puberty in patients with LM and VM to assess whether the onset of puberty results in higher treatment frequency.

METHODS

A retrospective review of head and neck LM and VM patients who were evaluated between January 2009 and December 2019 was performed. Patient demographics, lesion characteristics, and procedural details were recorded. For the purposes of this study, 11 years or older in females and 12 years or older in males were the established cut-offs for the onset of puberty.

RESULTS

After initial screening of 357 patients, 83 patients were included in the study based on inclusion criteria. There were 34 patients with LM (41 %) and 49 with VM (59 %). The mean age at diagnosis was 6.1 ± 10.9 years (LM: 4.2 ± 7.0, VM: 7.4 ± 12.9, p = 0.489). 68 patients underwent treatments, which included sclerotherapy, surgical excision, and/or laser. For all patients, the average number of lifetime treatments when initiated before puberty was 3.78 ± 2.81 and when initiated after puberty was 2.17 ± 1.37 (p = 0.022). Patients diagnosed pre-puberty were more likely to undergo treatments vs. those diagnosed after puberty (OR 10.00, 95 % CI: 2.61-38.28, p < 0.001).

CONCLUSION

We found that the number of treatments was fewer in those who started treatment after puberty. This finding suggests that providers may elect to proceed with observation in asymptomatic patients, given that waiting until after the onset of puberty has not shown an increase in the procedural load on patients.

Arteriovenous malformation of the ear optimized with cinematic rendering images: A case presentation and review of literature

Arteriovenous malformations (AVMs) define rare aberrations in vascular morphogenesis. AVMs are typically present at birth, and unless they are stimulated to grow quickly by trauma, illness, or hormonal effects, they enlarge in proportion to an individual's growth. Clinical manifestations of AVMs are often linked to abnormal mass effects and blood perfusion. In this report, we describe a unique case of AVM of the left ear in a 24-year-old male, employing cinematic rendering along with a review of differential diagnosis and treatment options.

Clinical results of polidocanol sclerotherapy in venous malformation treatment: Patient-perceived improvement and satisfaction

PURPOSE

This study evaluated the results of polidocanol sclerotherapy in the treatment of venous malformations (VM) including patient satisfaction, perceived improvement, and predictors of satisfaction.

MATERIAL AND METHOD

Patients with VM that underwent polidocanol foam sclerotherapy between June 2013 and July 2021 in a single center were retrospectively evaluated. Patient demographics, VM, and treatment characteristics were analyzed. Patient-reported outcomes and satisfaction were analyzed with a questionnaire.

RESULTS

This study included 232 (136, 58.6%, female) patients. The mean age was 24.49 ± 12.45 years (range 3-72). The clinical response rate was 82.3%. The rate of satisfaction was 82.3%, and 116 (50%) patients were significantly satisfied. There were no major complications. Clinical response and VM margin were related to satisfaction (p < 0.01, p = 0.012, respectively). Clinical response to pretreatment swelling was related to significant satisfaction (p = 0.02).

CONCLUSION

Polidocanol sclerotherapy was safe and effective in VM treatment with high satisfaction and low complication rates.

Sociodemographic characteristics of pediatric patients with vascular malformations: Results of a single site study

Vascular malformations, the abnormal development of blood vessels, are a rare set of congenital anomalies. The sociodemographic factors associated with vascular malformations in pediatric patients are poorly understood. This study examined sociodemographic factors of 352 patients presenting to a single vascular anomaly center from July 2019 to September 2022. Characteristics such as race, ethnicity, sex, age at presentation, degree of urbanization, and insurance status were recorded. This data was analyzed by comparing the different types of vascular malformations, including arteriovenous malformation, capillary malformation, venous malformation (VM), lymphatic malformation (LM), lymphedema, and overgrowth syndrome. Patients were primarily white, not Hispanic or Latino, female, had private health insurance, and were from the most urban setting. No differences in sociodemographic factors were found among the different vascular malformations except patients with VM presented at a later age than patients with LM or overgrowth syndrome. This study provides novel insight into the sociodemographic factors of pediatric patients presenting with vascular malformations and indicates a need for their improved recognition for the timely initiation of treatment.

A pediatric posterior neck venous malformation with an endocranial extension

Venous malformations are frequently localized in the head and neck region. However, a cervical localization with an endocranial extension is rather a very uncommon occurrence. We present a case of a 4-year-old child who presented with a large posterior cervical mass evolving for a year, firm and painful at palpation. Imaging was required, revealing a posterior cervical mass with an extension to adjacent structures, a destruction of the occipital bone and an endocranial extension. A macrobiopsy of the mass showed numerous irregular vessels. A surgical treatment was performed due to the extension of the mass, the esthetic prejudice it caused and the uncertain diagnosis. Venous malformation diagnosis was confirmed by a histological examination of the resected piece. Surgical management was not associated with the mass recurrence in our case. Here, we aim at identifying the clinical and radiological features of venous malformations, and at describing the different therapeutic features of this condition.

Posttraumatic Vascular Anomalies in Hand Surgery-A Case-based Approach

The field of vascular anomalies (VA) has been subject to changes during the last few decades. The current classification of the International Society for the Study of Vascular Anomalies (ISSVA) offers a simple diagnostic structure. Hand surgeons commonly appear to have limited exposure to VA. Already recognized for more than 120 years, pyogenic granuloma (PG) is by far the most commonly described VA by different disciplines with accordingly diverse treatment strategies and theories behind it. Arteriovenous fistula (AVF), venous aneurysms (VAN), and venous malformations (VM) are, however, rare in hand surgery. With a compilation of four illustrative cases of posttraumatic entities such as AVF, VAN, VM, and PG, we would like to highlight possible daily exposure to VA in the general hand surgery practice. We discuss diagnostic and therapeutic options as well as the current literature with focus on posttraumatic VA.

Ultrasound-Guided Moving Shot Radiofrequency Ablation of Benign Soft Tissue Neoplasm

Background and Objective: To evaluate the effectiveness of radiofrequency ablation (RFA) using the moving-shot technique for benign soft tissue neoplasm. Materials and Methods: This retrospective study reviewed eight patients with benign soft tissue neoplasm presenting with cosmetic concerns and/or symptomatic issues who refused surgery. Six patients had vascular malformation, including four with venous malformation and two with congenital hemangioma. The other two patients had neurofibroma. All patients underwent RFA using the moving-shot technique. Imaging and clinical follow-up were performed in all patients. Follow-up image modalities included ultrasound (US), computed tomography (CT), and magnetic resonance (MR) imaging. The volume reduction ratio (VRR), cosmetic scale (CS), and complications were evaluated. Results: Among the seven patients having received single-stage RFA, there were significant volume reductions between baseline (33.3 ± 21.2 cm³), midterm follow-up (5.1 ± 3.8 cm³, p = 0.020), and final follow-up (3.6 ± 1.4 cm³, p = 0.022) volumes. The VRR was 84.5 ± 9.2% at final follow-up. There were also significant improvements in the CS (from 3.71 to 1.57, p = 0.017). The remaining patient, in the process of a scheduled two-stage RFA, had a 33.8% VRR after the first RFA. The overall VRR among the eight patients was 77.5%. No complications or re-growth of the targeted lesions were noted during the follow-up period. Of the eight patients, two received RFA under local anesthesia, while the other six patients were under general anesthesia. Conclusions: RFA using the moving-shot technique is an effective, safe, and minimally invasive treatment for benign soft tissue neoplasms, achieving mass volume reduction within 6 months and significant esthetic improvement, either with local anesthesia or with general anesthesia under certain conditions.

Characteristics of mucocutaneous vascular malformations drawn from a decade of a multidisciplinary committee experience

Vascular malformations (VM) are congenital, benign, and relatively frequent lesions. Scant data have been published about the epidemiology, clinical presentation, and treatment of VM from a dermatologist's perspective. The substantial differences between subtypes, broad range of specialists consulted and confusing nomenclature used over previous years may hamper a correct diagnosis. The main objective of this study is to describe VM epidemiology. As a secondary endpoint we evaluate clinical characteristics, clinical-radiological correlation and treatment approaches. We carried out an observational, descriptive, retrospective study. Cases presented to the multidisciplinary committee of our hospital from 2009 to 2019 were retrieved. Electronic medical records, monthly committee reports and the iconographic archive were reviewed and statistically analyzed. Overall, venous malformations (VeM) are the most frequent VM, followed by capillary malformations (CM), arterioVeM and lymphatic malformations (LM). Considering only patients under 16, CMs are the most frequent ones. Capillary and LMs are larger than venous or arteriovenous. While CMs are usually asymptomatic, symptomatic cases are threefold more frequent in the other subtypes. Decisions on active or conservative management depend on VM size but not location or patient age. CMs are mainly treated with laser therapy; venous with sclerotherapy or surgery; arteriovenous with surgery and lymphatic with surgery or sirolimus. Dermatologists play an important role in VM diagnosis and management. Our 10-year multidisciplinary experience should contribute to the literature and represent a practical resource for clinicians and researchers.

Anomalous Presentation of Venous Malformations in an Adolescent Male

Venous malformations (VMs) may manifest clinically in a broad spectrum. Most VMs are sporadic with previous studies reporting less than 1.2% to be inherited. Conversely, multifocal lesions, such as glomuvenous malformations (GVMs), which have glomus cells in their vascular walls, have been reported to have a frequency of inheritance of 63.8%. Both VMs and GVMs may occur due to sporadic mutation and must be differentiated clinically because this will dictate their proper treatment. Sporadic GVMs involve skin and subcutis, with bluish-purple coloration, are painful to compression, and have no radiographic evidence of phleboliths. Previous studies have demonstrated that VMs are almost always associated with a single lesion that is nontender to compression and are often able to be diagnosed by the presence of phleboliths on radiographic imaging. We present a case of a 14-year-old right-hand-dominant male who presented with two distinct VMs on the dorsum of the right index finger at the proximal and middle phalanges. A previously biopsied lesion overlying the ipsilateral olecranon, which was reported as a possible glomus tumor versus vascular malformation, was present as well. Based on history, physical examination, multicentric presentation, and radiographic findings, the presumptive diagnosis was that the lesions were GVMs. However, after surgical excision and histopathologic examination, the lesions were determined to be VMs because of the absence of glomus cells. Due to the difference in treatment modalities for VMs and GVMs, the ability to accurately diagnose these lesions clinically is essential. This case represents an anomalous presentation of multiple venous malformations occurring in two distinct locations in a 14-year-old boy.

Management of Venous Malformations

Venous malformations (VMs) are slow-flow, congenital vascular anomalies that are a result of vascular dysgenesis. Clinical presentation and morbidity depend on size, location, and association with other syndromes. VMs are the most common symptomatic vascular anomaly referred for intervention, usually due to thrombosis, swelling, mass effect, functional compromise, or cosmetic concerns. Treatment for larger lesions can be challenging and a multidisciplinary approach involving medical, interventional, and surgical input is critical for comprehensive care. This article will assist the interventional radiologist in patient assessment and will discuss current techniques for treatment, means to minimize adverse events, and expected outcomes.

Congenital Disseminated Pyogenic Granuloma: Characterization of an Aggressive Multisystemic Disorder

OBJECTIVE

To describe the clinical, radiologic, and histopathologic features of "congenital disseminated pyogenic granuloma" involving various organs with high morbidity related to cerebral hemorrhagic involvement.

STUDY DESIGN

We searched the database of the Vascular Anomalies Center at Boston Children's Hospital from 1999 to 2019 for patients diagnosed as having multiple vascular lesions, visceral vascular tumors, congenital hemangiomatosis, multiple pyogenic granulomas, or multiple vascular lesions without a definite diagnosis. A retrospective review of the medical records, photographs, histopathologic, and imaging studies was performed. Only patients with imaging studies and histopathologic diagnosis of pyogenic granuloma were included.

RESULTS

Eight children (5 male, 3 female) had congenital multifocal cutaneous vascular tumors. Lesions also were found in the brain (n = 7), liver (n = 4), spleen (n = 3), muscles (n = 4), bone (n = 3), retroperitoneum (n = 3), and intestine/mesentery (n = 2). Less commonly affected were the spinal cord, lungs, kidneys, pancreas, and adrenal gland (n = 1 each). The mean follow-up period was 21.8 months. The cerebral and visceral lesions were hemorrhagic with severe neurologic sequelae. The histopathologic diagnosis was pyogenic granuloma with prominent areas of hemorrhage and necrosis. The endothelial cells had enlarged nuclei, pale cytoplasm and were immunopositive for CD31 and negative for D2-40 and glucose transporter 1.

CONCLUSIONS

Congenital disseminated pyogenic granuloma is a distinct multisystemic aggressive disorder that primarily affects the skin, brain, visceral organs, and musculoskeletal system. Differentiation of this entity from other multiple cutaneous vascular lesions is critical because of possible cerebral hemorrhagic involvement.

An integrated multidisciplinary team approach to the management of vascular anomalies: challenges and benefits

BACKGROUND

Vascular anomalies comprise highly variable pathophysiology and commonly pose diagnostic and management dilemmas. Consequently, patients often benefit from input from multiple specialists. This study describes the inception of a multidisciplinary team (MDT) Vascular Anomaly Clinic (VAC) in a tertiary paediatric centre, and the subsequent experience managing this complex patient group.

METHODS

This was a retrospective study of paediatric patients (< 18 years old) attending an MDT VAC from its inception in October 2012 until November 2019. Patient demographics, presentation, diagnosis and management were reviewed.

RESULTS

One hundred and thirty-three paediatric patients were seen over 7 years with a median age of 9.8 years. Vascular malformations were the most common diagnosis (88%), with venous malformations predominating (27%). The most common symptoms were pain (46%) and swelling (34%). Patients often required ≥ 2 investigations, with Doppler ultrasound (86%) and magnetic-resonance imaging (61%) being most common. Management included surgery (27%), sclerotherapy (26%), compression garments (23%), analgesia (12%), laser (15%), embolisation (5%) and sirolimus (3%).

CONCLUSIONS

The complex nature of vascular anomalies and high proportion of patients requiring multi-specialty management justified the establishment of an MDT VAC in our centre. Our experience demonstrates the success of an efficient one-stop MDT environment in the management of these challenging conditions.

LEVEL OF EVIDENCE

IV.

DSA-guided percutaneous sclerotherapy for children with oropharyngeal low-flow venous malformation

The present study investigated the efficacy and safety of digital subtraction angiography-guided 3% polidocanol foam sclerosing agent, as well as the combination of pingyangmycin and dexamethasone, for the treatment of children with oropharyngeal low-flow venous malformation. A total of 27 children with 35 lesions with oropharyngeal low-flow venous malformation were included. The subjects were randomly divided into Groups A (13 patients with 16 lesions, treated with 3% polidocanol foam sclerosing agent) and B (14 patients with 19 lesions, treated with pingyangmycin + dexamethasone), respectively. The clinical efficacies and adverse reactions were analyzed and compared between these two groups. The average number of treatment times for Group A was 2.45±0.6, with an efficacy rate of 87.50%, while the average number of treatment times for Group B was 2.07±0.4, with an efficacy rate of 84.21%. No significant difference was found in the average treatment times or efficacy rates between Groups A and B. In addition, the adverse reaction incidence for Groups A and B were 38.46 and 14.29%, respectively, with statistically significant differences between these two groups. The combination of pingyangmycin and dexamethasone was safe and effective in treating children with oropharyngeal low-flow venous malformation, with fewer adverse reactions and is worthy of clinical promotion.

Interim results of bleomycin-polidocanol foam sclerotherapy as a highly efficient technique for venous malformations

OBJECTIVE

The objective of this study was to retrospectively review the clinical and radiographic outcomes of patients with venous malformations (VMs) treated with bleomycin-polidocanol foam (BPF) sclerotherapy.

METHODS

The Institutional Review Board waived ethical approval for this retrospective review in which 55 patients (31 female and 24 male patients; mean age, 18.8 years; range, 2-60 years) were treated with BPF sclerotherapy. The stability (half-life) of BPF compared with polidocanol foam was studied. Standard sclerotherapy techniques were used. A total of 111 sclerotherapy sessions were performed, with a mean of 2.0 treatments per patient (range, 1-6). An average of 10 mL of BPF was used per procedure, with the total amount ranging from 2.5 to 30 mL. Symptoms before and after treatment, follow-up time, complications, and volume reduction on magnetic resonance imaging were recorded.

RESULTS

The median half-lives of the BPF and polidocanol foam were 238.25 ± 3.86 seconds and 194.33 ± 3.5 seconds, respectively. A t-test indicated significant differences between the groups (P < .01). The mean follow-up was 14 months (range, 6-24 months). All 55 patients (100%) reported improvement in symptoms. The total excellent and good response rate was 94.6%. An excellent response was achieved in 32 cases (58.2% [32/55]), a good response in 20 cases (36.4% [20/55]), and a poor response in 3 cases (5.4% [3/55]). Postprocedural magnetic resonance imaging demonstrated volume reduction of treated lesions in 54 of 55 patients (98%), with a mean lesion volume reduction of 84.6%. Postprocedure complications were minor in 13 of 111 procedures (12%) that were performed on 10 of 55 patients (18.2%), and no major complications occurred.

CONCLUSIONS

BPF sclerotherapy of VMs is safe and effective. BPF sclerotherapy can be a promising first-line treatment of VMs.

Arteriovenous Malformation MAP2K1 Mutation Causes Local Cartilage Overgrowth by a Cell-Non Autonomous Mechanism

Extracranial arteriovenous malformation (AVM) is most commonly caused by MAP2K1 mutations in the endothelial cell. The purpose of this study was to determine if local tissue overgrowth associated with AVM is caused by direct or indirect effects of the MAP2K1 mutation (i.e., cell-autonomous or cell-non autonomous). Because cartilage does not have blood vessels, we studied ear AVMs to determine if overgrown cartilage contained AVM-causing mutations. Cartilage was separated from its surrounding tissue and isolated by laser capture microdissection. Droplet digital PCR (ddPCR) was used to identify MAP2K1 mutations. MAP2K1 (p.K57N) variants were present in the tissue adjacent to the cartilage [mutant allele frequency (MAF) 6-8%], and were enriched in endothelial cells (MAF 51%) compared to non-endothelial cells (MAF 0%). MAP2K1 mutations were not identified in the overgrown cartilage, and thus local cartilage overgrowth likely results from the effects of adjacent mutant blood vessels (i.e., cell-non autonomous).

Sclerotherapy for Venous Malformations of the Pharynx or the Tongue Base Without Tracheostomy: Treatment Protocol With Intubation and Outcomes

Venous malformations (VMs) occurring in the tongue base or pharynx are rare, but can cause airway obstruction. Considering the potential issues or morbidity related to surgical resection in the tongue or pharynx region, sclerotherapy is often preferred. We perform sclerotherapy for such lesions without conducting tracheotomy, but keep patients intubated for a certain period. Outcomes of sclerotherapy, and benefits and cautions related with our protocol were investigated.Our subjects were 10 cases in 9 patients who underwent sclerotherapy for VMs of the tongue base (6 patients) or pharynx (3 patients) from 2008 to 2017. One patient underwent treatment sessions twice. The sclerosants used were absolute ethanol (ET) (3 cases), 5% ethanolamine oleate (EO) (4 cases), or both ET and 5%EO (3 cases).In 5 of 9 patients, postoperative MRI was performed, which revealed lesion volume reduction by 12% to 47%. The intubation period varied according to the sclerosant used: ET, 5 to 11 days; 5% EO, 2 to 12 days; and combination of ET and 5% EO, 8 days. Postoperative complications included fever of unknown (n = 2), acute psychosis (n = 3), vocal cord paralysis (n = 2), and bradycardia induced from the use of a sedative agent (n = 1). One patient complained of mild transient swallowing difficulty that lasted for a month postoperatively.Although our method mandatorily requires careful postoperative management in an ICU, including sedation with anesthetic agents and artificial respiration by intubation for a certain period of time, no serious complications or post-therapeutic morbidities occurred.

Bleomycin Polidocanol Foam (BPF) Stability - In Vitro Evidence for the Effectiveness of a Novel Sclerosant for Venous Malformations

OBJECTIVE

This study investigated the in vitro stability of a novel sclerosant, bleomycin polidocanol foam (BPF), for venous malformation (VM) sclerotherapy.

METHODS

The study was designed with control groups treated with polidocanol (0.5%, 1%, and 3%) only. The experimental groups included 21 BPFs, which was made by dissolving bleomycin at seven different concentrations (0.1%-1.5%) in polidocanol (0.5%, 1%, and 3%). The Tessari method was used to prepare sclerosant foam with a liquid:gas ratio of 1:4 at room temperature in vitro. The foam stability was measured for each group. The decay process, one component of foam stability, was recorded with a camera. Foam decay process experiments were performed 10 times per group. The stability indices included drainage rate, drainage time, half life, and microscopic measurement of the foams (mean bubble diameter, minimum and maximum bubble diameters, wall thickness, and bubble diameter distribution).

RESULTS

Compared with the control groups, the half lives of BPFs mainly increased significantly with the addition of bleomycin (p < .001). BPF with 3% polidocanol and 0.1% bleomycin recorded the highest half life (246 ± 1.6 sec), and this group also achieved the smallest bubble diameter and wall thickness (69.9 μm and 5.80 μm) among the experimental groups. For the same polidocanol concentration, the bubble diameter and wall thickness increased when bleomycin was added.

CONCLUSION

Bleomycin concentrations account for different BPF stability. BPF stability mainly increased significantly with the addition of a small amount of bleomycin but this advantage was no longer apparent with increasing bleomycin dose.

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.

Effect of foam and liquid bleomycin in the management of venous malformations in head and neck region: A comparative study

BACKGROUND

Many treatment options for venous malformations (VMs) have been documented in the literature, but injection sclerotherapy has been considered a current mainstay for their treatment. We conducted this study to determine the efficacy and durability of injection of different forms of bleomycin sclerotherapy in the treatment of VMs in the cervico-facial region.

PATIENTS AND METHODS

Thirty patients with clinically diagnosed VMs of the head and neck region, confirmed by magnetic resonance imaging, had been injected with the bleomycin sclerosing material. They were divided into 2 groups according to the form of bleomycin injected: in Group A, the foam form was injected, and in Group B, the liquid form was injected. Data of patients' demographics, anatomical sites, type and volume of the VMs, number of injection sessions and the average dose of injected agents were documented and statistically compared between the 2 groups.

RESULTS

MRI showed a decline of more than 90% from the initial size of the lesions in 66.7% of the cases and considerable decline (60-90%) in 33.3% of the cases. In Group A, the number of sessions and the amount of sclerosant material injected were lower than those in Group B. The cumulative dose in the equal-sized lesions was lower in the foam form than in the liquid form.

CONCLUSION

We recommend using bleomycin in its foam form on a greater number of patients with larger VMs and in different sites, as the results are more promising in this form than in the liquid form.

Vascular anomalies of the head and neck: current overview

Vascular anomalies are disorders of the endothelium and surrounding cells that can affect the vasculature and involve any anatomical structure. The most common problem associated with vascular anomalies is psychological distress related to disfigurement as well as functional defects, as many lesions affect the head and neck. This article provides an overview of the current clinical features that distinguish the major types of vascular anomalies that affect the head and neck.

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.

Localised intravascular coagulation complicating venous malformations in children: Associations and therapeutic options

Venous malformations are slow-flow congenital vascular malformations that enlarge as the child ages and may be associated with localised intravascular coagulation, a consumptive coagulopathy characterised by elevated D-dimer and decreased fibrinogen levels. The authors review the known correlations between localised intravascular coagulation and venous malformation number, size and planes involved, and call attention to the concept of the progression of localised intravascular coagulopathy as the child ages and their venous malformations enlarge. The authors also discuss the identified therapeutic options for its investigation, management and treatment, including compression garments, anti-coagulation therapy, sclerotherapy, endovascular laser, surgical excision and sirolimus (rapamycin). Evidence for protocol improvements that may be instigated for the optimal physical and medical therapy of venous malformations complicated by localised intravascular coagulopathy is reviewed.

Shared Decision-Making in the Management of Congenital Vascular Malformations

BACKGROUND

In shared decision-making, clinicians and patients arrive at a joint treatment decision, by incorporating best available evidence and the patients' personal values and preferences. Little is known about the role of shared decision-making in managing patients with congenital vascular malformations, for which preference-sensitive decision-making seems obvious. The authors investigated preferences regarding decision-making and current shared decision-making behavior during physician-patient encounters.

METHODS

In two Dutch university hospitals, adults and children with congenital vascular malformations facing a treatment-related decision were enrolled. Before the consultation, patients (or parents of children) expressed their preference regarding decision-making (Control Preferences Scale). Afterward, participants completed shared decision-making-specific questionnaires (nine-item Shared Decision-Making Questionnaire, CollaboRATE, and satisfaction), and physicians completed the Shared Decision-Making Questionnaire-Physician questionnaire. Consultations were audiotaped and patient involvement was scored by two independent researchers using the five-item Observing Patient Involvement instrument. All questionnaire results were expressed on a scale of 0 to 100 (optimum shared decision-making).

RESULTS

Fifty-five participants (24 parents and 31 adult patients) were included. Two-thirds preferred the shared decision-making approach (Control Preferences Scale). Objective five-item Observing Patient Involvement scores were low (mean ± SD, 31 ± 15), whereas patient and physician Shared Decision-Making Questionnaire scores were high, with means of 68 ± 18 and 68 ± 19, respectively. The median CollaboRATE score was 93. There was no clear relationship between shared decision-making and satisfaction scores.

CONCLUSIONS

Although adults and parents of children with vascular malformations express a strong desire for shared decision-making, objective shared decision-making behavior is still lacking, most likely because of poor awareness of the shared decision-making concept among patients, parents, and physicians. To improve shared decision-making practice, targeted interventions (e.g., decision aids, staff training) are essential.

Management of Orbital and Periorbital Venous Malformation

BACKGROUND

To review our management of common venous malformation (VM) affecting the orbit and/or periorbital area.

METHODS

Consecutive patients with orbital and/or periorbital VM were identified from our vascular anomalies database. Demographic details of the patients, anatomic site(s) affected, symptoms and signs, presence of a family history of VM, and types of treatment(s) were collected, supplemented by chart review.

RESULTS

A total of 24 patients' age 1-68 (mean, 30) years with orbital and/or periorbital VM presented with cosmetic concerns (n = 17, 71%), distensibility (n = 15, 63%), pain (n = 9, 38%), diplopia (n = 4, 17%), and spontaneous thrombosis (n = 1, 8%). The VM caused globe dystopia (n = 13, 54%), enophthalmos (n = 6, 25%), proptosis (n = 3, 12%), exotropia (n = 3, 12%), and pseudoptosis with visual obstruction (n = 3, 13%). A total of 11 (46%) patients were managed conservatively. 13 (54%) patients underwent active treatment. Ethanol sclerotherapy (ES) was performed in six patients with extensive facial VM associated with orbital/periorbital involvement, resulting in symptomatic improvement in five patients, one of whom developed skin necrosis and another patient developed reduced infraorbital nerve sensation. Surgery was performed for localized lesion (n = 3, 23%), for extensive lesions (n = 4, 31%) and as an adjunct to ES (n = 6, 46%) resulting in symptomatic improvement in all patients. One patient required correction of lower lid ectropion.

CONCLUSION

Orbital and/or periorbital VMs are heterogeneous, and management needs to be individualized. Surgery is used for localized lesions aiming for complete excision, as a debulking procedure for extensive orbital/periorbital VM when ES was not possible, or following ES for extensive facial VM with orbital and/or periorbital involvement.

Curative effects of RF combined with DSA-guided ethanol sclerotherapy in venous malformations

The aim of the study was to investigate the clinical effect of radiofrequency (RF) ablation combined with digital subtraction angiography (DSA)-guided anhydrous ethanol injection sclerotherapy in the treatment of high-return flow venous malformation (VM). Forty-one patients who were diagnosed as high-return flow VM with clinical and radiographic evidence were divided into the observation group (n=19) and control group (n=22) by random number table. All the patients received DSA-guided anhydrous ethanol injection sclerotherapy while the patients in the observation group were given RF ablation in addition. The clinical effect, treatment times and adverse effects of the two groups were analyzed. The effectiveness of the observation group was significantly higher than that of the control group (94.7 vs. 81.8%). Facial paralysis occurred in three patients (13.6%) after ethanol injection in the control group, while the observation group had no facial nerve injury after treatment. The patients in the observation group had significantly fewer number of ethanol injections. RF can improve the efficacy of high-return flow VM and reduce the number of ethanol injections. The scheme is safe and effective, which is worth expanding in clinical practice.

The Efficiency of Sclerotherapy in the Treatment of Vascular Malformations: A Retrospective Study of 63 Patients

Background and Aims. Vascular malformations are a vast group of congenital malformations that are present at birth. These malformations can cause pain, pressure, and cosmetic annoyance as well as downturn growth and development in a child in the case of high flow. Sclerotherapy has become an important tool in the treatment of vascular malformations. However, little is known about the success rate of sclerotherapy. Material and Methods. In this study, the efficiency of sclerotherapy in the treatment of vascular anomalies was investigated retrospectively in 63 patients treated in Turku University Hospital between 2003 and 2013. Results. Out of the 63 patients investigated, 83% (53) had venous malformations (VMs) and 9% (5) were defined as having arteriovenous malformations (AVMs). Patients with a VM were operated on, in 14% (8) out of all VM cases. Hence 86% (45) of patients with a VM received adequate help to their symptoms solely from sclerotherapy. The duration of treatment for the 14% of the VM patients that needed a surgical procedure was prolonged by 7–9 months, that is, by 41%. Conclusions. Sclerotherapy is an effective method in the treatment of VMs with a satisfactory clinical response in patients symptoms in 84% of cases.

Compression therapy for congenital low-flow vascular malformations of the extremities: A systematic review

Introduction Low-flow vascular malformations are congenital abnormalities of the veins, capillaries or lymphatic vessels or a combination of the previous. Compressive garments are frequently used as a first-line treatment option for low-flow vascular malformations of the extremities with the purpose of relieving symptoms. Yet, the benefits and harms of compression stockings remain unclear. Methods A systematic search was performed in MEDLINE, Embase, Cochrane Central Register of Controlled Trials including a hand search for studies measuring the benefits and harms of compression garments in treating low-flow vascular malformations. Two investigators performed study selection, quality assessment and data extraction independently. Results Of the 565 studies found, eventually five (totalling 101 patients with venous malformations or Klippel-Trenaunay syndrome receiving compression therapy) observational studies were included in the systematic review. Although the overall quality of these studies was poor, results suggest that compression garments might lessen intravascular coagulation, improve symptoms and appearance, diminish oedema, and protect against minor trauma. None of the studies quantified any harms of compression therapy. Conclusion Even though compression therapy is commonly used in the treatment of low-flow vascular malformations, available literature does not provide high-quality evidence to validate its use. We therefore advocate the need for prospective comparative trials with standardised outcome measures to study the benefits and harms of this treatment option.

Sclerotherapy complications of peripheral venous malformations

Background Sclerotherapy is often the primary treatment for peripheral venous malformations. It is mostly sufficient alone, but can be combined with other endovascular techniques. Despite its mini-invasiveness, it is not without potentially severe complications. Here, we systematically report sclerotherapy complications in trunk and extremity venous malformations. Methods We retrospectively assessed the complications of 127 consecutive patients who had received sclerotherapy for peripheral venous malformation in our tertiary care unit (January 2007-August 2013). We applied the Clavien-Dindo classification to grade the severity of complications. We mostly used detergent sclerosants (85.7%), and less often ethanol (5.7%) or bleomycin (4.2%). In 4.2% of the procedures, we combined glue, coils, endovascular laser or particles to sclerotherapy. Results The overall complication rate per procedure was 12.5%. Most complications (83.3%) were local and managed conservatively. We encountered four severe complications, all related to blood coagulopathy. Subcutaneous lesion location and use of ethanol significantly increased the risk of local complications. Conclusion Sclerotherapy alone or combined with other endovascular techniques is a safe method for local venous malformations with moderate risk for conservatively manageable complications. Blood coagulopathy constitutes a risk for, otherwise rare, severe complications.

Bleomycin Foam Treatment of Venous Malformations: A Promising Agent for Effective Treatment with Minimal Swelling

PURPOSE

To report clinical and radiographic outcomes of patients with venous malformations (VMs) treated with bleomycin foam.

MATERIALS AND METHODS

Twenty patients (age, 2-68 y) presented with symptoms of swelling (n = 19; 95%), pain (n = 14; 70%), and bleeding (n = 4; 20%). Lesions were located in the head and neck in 17 patients (85%), extremities in two (10%), and mediastinum in one (5%). Twenty-seven embolizations were performed, with a mean of 1.7 ± 1.0 treatments per patient (range, 1-4). An average of 0.45 ± 0.4 U/kg of bleomycin foam was used per procedure, with a range of 0.1-2.3 U/kg.

RESULTS

All procedures were technically successful with no intraprocedural complications. Mean follow-up was 66 days ± 80, with a range of 4-403 days. Postprocedure complications were minor in 6 of 27 procedures (22%) and major in 2 of 27 procedures (7%). All 20 patients (100%) reported improvement in their symptoms after a single treatment session. Postprocedural magnetic resonance (MR) imaging demonstrated volume reduction of treated lesions in 13 of 14 patients (93%), with a mean lesion volume reduction of 66% ± 21. Enhancement on MR imaging after treatment was decreased in 11 of 14 patients (79%), increased in two (14%), and stable in one (7%). T2 signal intensity on MR imaging after treatment was decreased in 12 of 14 patients (86%) and stable in two (14%).

CONCLUSIONS

The use of bleomycin foam for the percutaneous treatment of VMs is safe and effective. Foaming bleomycin may be used to address the dose limitations of the liquid.

Ethanol sclerotherapy for venous malformation

BACKGROUND

Ethanol sclerotherapy (ES) is the preferred treatment for venous malformation (VM) with surgery playing an adjunctive role. Results of ES, however, are not well documented in the literature.

METHODS

VM patients were identified from our vascular anomalies database from 1996 to 2011. After treatment completion, patients completed questionnaires evaluating symptoms and their severity and effect on appearance, function and overall quality of life (QoL), before and >6 months after treatment, using visual analogue scales of 0-10. Patients rated their overall satisfaction with ES using a scale of 0-10.

RESULTS

Fifty-four (23.9%) of the 226 VM patients underwent a total of 90 ES sessions (average 1.7 sessions per patient). Complications occurred in 12 (22.2%) patients in 12 (13.3%) ES sessions. Minor complications occurred in nine (16.7%) patients including transient paraesthesia (n = 3), transient weakness of facial nerve branch(es) (n = 3), skin blistering (n = 2) and spontaneously healing ulceration (n = 1). Major complications occurred in three (5.6%) patients in three (3.3%) ES sessions including skin necrosis (n = 1), Horner's syndrome (n = 1) and finger paraesthesia with joint stiffness (n = 1). ES improved the severity of background pain, episodic pain, contour deformity and skin discoloration in 86.0%, 72.4%, 83.0% and 72.2% of patients respectively. It reduced the effect of VM on appearance, function and overall QoL in 69.8%, 73.0% and 64.3% of patients. Mean treatment satisfaction was 7.9 (range, 0-10).

CONCLUSION

ES reduces pain, contour deformity and skin discoloration, and improves appearance, function and QoL. Our complication rates are consistent with the literature.

Effectiveness of sclerotherapy, surgery, and laser therapy in patients with venous malformations: a systematic review

PURPOSE

Because the best possible treatment for venous malformations is unclear, this study systematically reviews the available literature regarding the effectiveness of different treatment options for the patient group. Venous malformations result from incorrect development of the veins during embryogenesis and are present at birth. Venous malformations may exhibit symptoms, such as pain, swelling, and inflammation of the vessel.

MATERIALS AND METHODS

A systematic literature search in PubMed and Embase was performed. Data regarding the design, participants, intervention and, treatment outcome (success and complications) were extracted. The validity of the studies was assessed with the Cochrane Collaboration's risk of bias tool.

RESULTS

Thirty-five studies were identified studying the effectiveness of eight treatments: sclerotherapy/embolization with ethanol, gelified ethanol, bleomycin, polidocanol, sodium tetradecyl sulfate (STS), Ethibloc, surgery, and laser therapy. All of the included studies have a high or unclear risk of bias. The average biased reported success rates for ethanol, gelified ethanol, bleomycin, polidocanol, STS, Ethibloc, surgery, and laser therapy were 74, 89, 88, 90, 86, 65, 90, and 94 %, respectively.

CONCLUSION

Until more valid evidence is available, the choice for treatment remains a shared decision between the patient and a multidisciplinary treatment group. From a cost perspective, sclerotherapy with STS or polidocanol should be the treatment of choice.

Complex vascular anomalies

The classification system for vascular anomalies now used by experts worldwide comprises two distinct disease entities that differ in their biologic and pathologic features: vascular tumors and vascular malformations. Vascular tumors include infantile and congenital hemangiomas, tufted angiomas, and kaposiform hemangioendotheliomas. Infantile hemangiomas, the most common vascular anomaly, generally have a predetermined life cycle (proliferation and subsequent involution). GLUT-1, a glucose transporter, is a marker for these specific lesions during all phases of development. Vascular malformations are classified according to their vascular tissue of origin and include capillary, venous, arteriovenous, lymphatic, and mixed malformations. Complex lymphatic malformations and complex mixed malformations, which may have most vascular components, are the most difficult vascular malformations to successfully treat. These lesions are present at birth and often expand or grow in response to trauma, infection, or hormonal changes. Imaging advancements have enabled more accurate assessments and improved management of vascular anomalies. In addition, many lesions are now being managed with targeted pharmacologic therapy. Propranolol and steroids are used for complex or disfiguring tumors, and new anti-angiogenesis inhibitors such as sirolimus are selectively used to treat lymphatic and venous lymphatic malformations that are poorly responsive to sclerotherapy, embolization, and surgical excision. Multimodal therapies are often essential for complex lesions and require the combined expertise of an interdisciplinary team.

Comparison between absolute ethanol and bleomycin for the treatment of venous malformation in children

The aim of this study was to investigate the therapeutic efficacies and treatment effects of absolute ethanol and bleomycin for the treatment of venous malformation (VM) in children. A total of 138 children with VM were randomly divided into two groups; 75 patients were treated with absolute ethanol, while a further 63 were treated with bleomycin under general anesthesia between February 2009 and February 2012. The treatment outcome and complications were observed in the two groups and the treatment efficacy was classified as one of four categories: cured, markedly effective, effective and ineffective. The curative effect was analyzed 6–24 months after treatment, with a mean of 15 months. Absolute ethanol was effective (cured, markedly effective or effective) in 71 cases and bleomycin was effective in 41 cases, and the difference between the effective rates was considered to be statistically significant (χ²=19.6, P<0.05). In the absolute ethanol group there were 14 cases with skin necrosis, 17 patients had serious localized swelling which required additional treatment, three patients developed muscle fibrosis and one patient suffered a brain embolism. In the bleomycin group there were five cases with skin necrosis and the difference in the incidence of adverse reactions was considered to be statistically significant (χ²=18.8, P<0.05). The curative effect of sclerotherapy for VM is clear, and absolute ethanol is the most effective sclerosing agent, but has a greater incidence of adverse side-effects than bleomycin. The major side-effect is skin necrosis. The choice of sclerotherapy depends on the classification of VM in children.

Vascular anomalies - a practical approach

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.

Gross hemoglobinuria and oliguria are common transient complications of sclerotherapy for venous malformations: review of 475 procedures

OBJECTIVE

The purpose of this article is to study the incidence, risk factors, and treatment of gross hemoglobinuria and oliguria following sclerotherapy for venous malformations.

MATERIALS AND METHODS

The clinical records and imaging studies of 131 patients with venous malformations (57 male and 74 female patients; age range, 2-58 years) who underwent sclerotherapy at our institution between July 1993 and August 2007 were reviewed. Demographic data, the location and estimated size of the malformation, the type and dose of the sclerosing agents, development of postprocedural hemoglobinuria and oliguria, and the treatment given were documented and analyzed.

RESULTS

Four hundred seventy-five sclerotherapy procedures were performed on 131 patients, with the number of procedures per patient ranging from 1 to 21 (mean, 3.6 procedures). Sodium tetradecyl sulfate was used in 47% of the procedures, ethanol in 27%, and both agents in 26%. Transient hemoglobinuria occurred after 34% of the sclerotherapy procedures, and 57% of these were associated with transient oliguria, with increased risk with higher adjusted doses (sclerosant volume/weight of patient) for both agents. Resolution of the hemoglobinuria and oliguria with hydration, alkalinization, and diuretics occurred in all patients. The risk of hemoglobinuria increased with higher adjusted dose (sclerosant volume/weight of patient) for both agents and with sclerotherapy of venous malformations affecting the lower extremities and multiple locations.

CONCLUSION

Transient hemoglobinuria and oliguria are common complications of sclerotherapy for venous malformation. Nevertheless, with proper fluid management, all the patients promptly recovered. The risk correlates with the volume of sclerosant (adjusted to patient's weight) and is higher for lower extremity and multiple locations.

Vascular anomalies in children

The process of understanding and treating children with vascular anomalies has been hampered by confusing and occasionally incorrect terminology. The most important step when evaluating a maxillofacial vascular anomaly is to determine whether it is a tumor or a malformation. In most cases, this diagnosis can be made by history and physical examination. Selective radiographic imaging is helpful in differentiating vascular malformations or the extent of bony involvement and/or destruction. Children with vascular anomalies should be managed by an interdisciplinary team of trained providers who are committed to following, treating, and studying patients with these complex problems.

Sodium tetradecyl sulphate sclerotherapy for treating venous malformations of the oral and pharyngeal regions in children

OBJECTIVE

Venous vascular malformations in the head and neck region present a difficult management challenge. We describe our experience of using sodium tetradecyl sulphate injection sclerotherapy to treat children presenting with venous malformations of the oral and pharyngeal region.

METHODS

We performed a retrospective case note review of consecutive children treated at our institution between 2004 and 2011. Patient notes were analysed for demographic details, site and size of lesion, number and duration of treatments, treatment response and complications.

RESULTS

Twelve patients were included (7 boys and 5 girls, mean age 7 years). Sites of lesions included tongue, floor of mouth, pharynx, tonsillar fossae, parapharyngeal space and soft palate. All patients were treated with 3% sodium tetradecyl sulphate (STS) foam injected trans-orally or percutaneously under ultrasound or fluoroscopic guidance. The lesions had a mean volume of 4 ml (range 2-14 ml). An average of 3 treatments was required (range 1-9). In 4 patients a single treatment was sufficient. For those patients requiring multiple treatments, a mean of 4 treatments were required over an average period of 28 months. The overall response rate was 83% (10/12). Complete resolution was achieved in 4 cases (33%) with a significant reduction in size in a further 6 cases (50%). Larger lesions generally require more treatments than low volume lesions. Two cases recurred despite treatment. One patient suffered minor bleeding following transcutaneous injection.

CONCLUSIONS

Injection sclerotherapy using STS foam offers an effective treatment option when managing children presenting with venous malformations in the oral and pharyngeal. A single treatment may be adequate for small lesions but the procedure may be safely repeated until a satisfactory result is obtained.