Colour duplex ultrasound-guided sclerotherapy: a new approach to the management of patients with peripheral vascular malformations

Endodontic implications of a patient with arteriovenous malformation: a case report and literature review

AIM

To present the endodontic management of a patient diagnosed with a high-flow arteriovenous malformation (AVM) requiring root canal treatment and to discuss the relevant endodontic literature for this rare but significant problem.

SUMMARY

AVM is a complex communication of an artery and a vein in which the oxygenated blood is forced away from the intended tissue. The incidence of its occurrence in the face and neck is rare, and when present, the most common sign is gingival bleeding. Arteriovenous malformation is both a diagnostic and therapeutic challenge for dentists. Also, there is ambiguity regarding the precautions to be taken whilst doing endodontic procedures in such cases. Hence, there is a need to understand the disease process and its implications in order to prevent life-threatening complications during treatment. This case report highlights the successful endodontic management of a cariously exposed right maxillary second premolar in a patient diagnosed with high-flow AVM. On an orthopantomogram, the AVM was spreading in the left submandibular space involving the left ramus area. The clinical findings of limited mouth opening with inter-appointment swelling and trismus during treatment made the case unusual and challenging. This paper addresses the current understanding of the classification, diagnosis, clinical features and endodontic management, together with specific guidelines and recommendations whilst performing endodontic procedures in AVM cases.

KEY LEARNING POINTS

The classification and oral manifestations of AVM must be known and understood. Practitioners should be aware of the radiographic appearance of AVM. Recommended precautions should be taken when carrying out restorative and endodontic procedures in a patient with AVM. Antibiotic prophylaxis may be considered before endodontic treatment in a patient with AVM. Multidisciplinary treatment planning may be required.

Outcomes and Complications of Sclerotherapy for Venous Malformations

Objective:

To determine the efficacy of sclerotherapy for venous malformations (VMs).

Methods:

PubMed was used to search the medical literatures for publication on the combined topics of “VMs and sclerotherapy.” The final evaluation of the venous lesions was based on both objective parameters and subjective parameters. Complications were also recorded.

Results:

A total of 35 studies published between 1986 and 2011 matched the selection criteria and were included. Ethanol, polidocanol, ethanolamine oleate, and sodium tetradecyl sulfate (STS) are the 4 mainstream sclerosants. The total efficiency of these 4 sclerosants all exceeded 90% except STS. Skin damage (10.0%) was the most common minor complication. Other complications included renal damage (3.9%), nerve damage (1.85%), muscle damage (0.66%), pulmonary embolism (0.25%), cardiovascular collapse (0.08%), and others.

Conclusions:

Sclerotherapy is effective for VMs. However, there is limited evidence from randomized clinical trials to support the use of any kinds of sclerosants.

Steigerung der Lebensqualität nach Schaumsklerosierung einer multipel voroperierten vaskulären Malformation

Vaskuläre Malformationen stellen aufgrund ihrer Seltenheit und heterogenen klinischen Ausprägung eine therapeutische Herausforderung dar. Im vorliegenden Fallbericht wurde eine ausgedehnte, vielfach voroperierte und stark schmerzhafte venöse Malformation bei einer 46-jährigen Patientin mit mehreren Schaumsklerosierungen erfolgreich behandelt. Es konnte eine bemerkenswert rasche, anhaltende Schmerzreduktion und eine Steigerung der Lebensqualität erzielt werden. Der Fall demonstriert, dass die Schaum -sklerosierungstherapie eine gute, nebenwirkungsarme Therapieoption bei operativ nicht mehr behandelbaren, anatomisch unübersichtlichen Malformationen sein kann.

Intralesional sclerotherapy for subcutaneous venous malformations in children

BACKGROUND

Venous malformations (VMs) involve multiple anatomical spaces and encase critical neuromuscular structures, making surgical treatment difficult. Recently sclerotherapy has been suggested as the primary treatment for VMs instead of surgical intervention. This report represents eight cases of children with VMs treated with direct percutaneous injections of sclerosing agents, such as ethanol, polidocanol or ethanolamine oleate.

METHODS

All eight patients had large lesions (>3 cm) located on the head, foot, neck and face. Sclerotherapy was performed in an angiographic suite under general anesthesia. Prior to sclerotherapy, percutaneous phlebography was performed in order to visualize the dynamic situation inside the lesion and the draining flow into the adjacent venous vascular system. A 2-15 ml of sclerosing agent was injected into VM lesions under fluoroscopy.

RESULTS AND CONCLUSIONS

An evaluation by MRI examination showed that 6 out of 8 patients had remission, and alleviation of their symptoms without major complications, furthermore one of the lesions apparently disappeared. Intralesional sclerotherapy provides a simple, safe and effective treatment for VMs in the subcutaneous lesions in children.

MR imaging-guided percutaneous sclerotherapy of peripheral venous malformations with a clinical 1.5-T unit: a pilot study

PURPOSE

To evaluate the feasibility of magnetic resonance (MR) imaging-guided percutaneous sclerotherapy of venous malformations (VMs) by using a clinical 1.5-T MR unit and the safety and therapeutic outcome of the performed procedures.

MATERIALS AND METHODS

This is a prospective pilot study with ethical approval and written informed patient consent. Ten MR imaging-guided percutaneous sclerotherapy treatments were performed in 10 patients (one male and nine female patients; age range, 16-47 years; mean age, 30.3 years) with a VM in the foot and/or ankle (n = 5), calf (n = 2), thigh and/or knee (n = 2), and elbow (n = 1). MR imaging was used for needle insertion guidance and real-time monitoring of the injection process by using three-dimensional fast spoiled gradient-echo MR sequences (repetition time msec/echo time msec = 3.7-5.2/1.1-1.6, flip angle = 35 degrees) and meglumine gadoterate/ethanol solutions as the sclerosing agent. The technical success (ie, absence of technical problems, number of needle position corrections) was systematically evaluated along with safety aspects (ie, absence of complications) and the therapeutic outcome (eg, VM volume decrease, relief of symptoms) during a 1-year follow-up period.

RESULTS

MR imaging-guided sclerotherapy was technically successful in all patients. A mean of 2.5 +/- 1.85 (range, 1-6) needle position corrections were needed for correct needle placement. The distribution of the sclerosing agent (mean amount, 10.5 mL; range, 0.8-33.0 mL) was clearly visible with real-time MR monitoring. One patient developed a compartment syndrome, which was managed with surgery. No other complications were observed. VM volumes significantly decreased by 53% (range, 24%-86%; P = .02) 12 weeks after therapy. Nine of the 10 patients (90%) noted an improvement of symptoms.

CONCLUSIONS

In this limited preliminary series, 1.5-T MR imaging-guided percutaneous sclerotherapy for the treatment of VMs was feasible with a high degree of technical success, was relatively safe, and had a good therapeutic outcome after 1 year.

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

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