Color duplex-guided sclerotherapy for the treatment of venous malformations

Effectiveness of polidocanol sclerotherapy in alleviating symptoms in patients with venous malformations

OBJECTIVE

The objective of this study was to retrospectively evaluate the effectiveness of polidocanol in managing pain, swelling, functional limiting and cosmetic disorders in patients with venous malformations (VMs).

METHODS

This retrospective study included patients who underwent sclerotherapy with polidocanol for VMs between 2020 and 2022. Patient records, imaging findings, and evaluation questionnaires used in the preprocedure and follow-up phases were reviewed. After sclerotherapy, patients were followed up at 1, 2, 3, and 6 months. During these visits, the previously used 11-point verbal numerical rating scale (from 0 [no pain] to 10 [worst pain thinkable]) was used to evaluate the severity of symptoms such as pain, swelling, cosmetic discomfort, and functional limitation, and patients were asked to report the number of days per week they experienced these symptoms owing to the VM.

RESULTS

A total of 194 sclerotherapy procedures (mean, 1.6 ± 0.3 procedures) in 84 patients (55 female and 29 male patients; mean age, 22.45 ± 11.83 years) were conducted. The majority of these malformations (81%, or 68 patients) were located in the extremities. We found a significant decrease in pain, swelling, functional limitation, cosmetic appearance, and number of painful days between all time points, except for the comparison between months 3 and 6 (P < .001) CONCLUSIONS: Polidocanol sclerotherapy is a safe and effective treatment for VMs that significantly decreases patient complaints and has a very low complication rate. Particularly, following patients at short intervals and administering additional sclerotherapy sessions when necessary will significantly increase patient satisfaction.

Effectiveness of Polidocanol in the Treatment of Venous Malformations: A Meta-Analysis

OBJECTIVE

The aim of this study was to investigate the efficacy of polidocanol against venous malformations (VMs).

METHODS

Studies reporting the treatment of VMs using polidocanol (published until February 15, 2020) were reviewed in the Embase and PubMed databases. After excluding the same literature, part of the studies were excluded by reading the title, abstract, full text. Eleven studies (with 287 participants) that fulfilled the inclusion criteria were included. Systematic meta-analysis was performed using Reviews Manager 5.2, and a fixed-effects model was used to calculate the pooled effective rate of polidocanol against VMs and the 95% confidence intervals (CI).

RESULTS

Lesion reduction of more than 50% was considered effective. A total of 287 patients were treated, and treatment in 271 was considered effective. The efficacy of polidocanol was 0.89 (95% CI = 0.83-0.93). Heterogeneity among the studies was small (I ² = 0%, P = 0.47). T The funnel plot was roughly symmetric.

CONCLUSION

Our study suggested that polidocanol is effective in the treatment of VMs. VMs at different sites can be treated without serious complications. Therefore, we have reason to believe that polidocanol is a safe and an effective drug for VMs.

Minimal Invasive Surgical Management of Familial Arteriovenous Malformation

INTRODUCTION

Familial arteriovenous malformations are exceedingly rare. They are often noted at birth. They can also present during childhood or adolescence. Sclerotherapy has proven to have a favorable outcome. Case Presentation. The present case report describes the treatment of arteriovenous malformations on the tongue, labial mucosa, and vermilion border in siblings treated with boiling saline injections.

CONCLUSION

Sclerotherapy using boiling saline had shown to effectively treat arteriovenous malformations in the oral region without any significant morbidity.

Efficacy and safety of DSA-guided percutaneous sclerotherapy for venous malformations of penile region in children

OBJECTIVE

To describe the effectiveness and security of DSA-guided percutaneous sclerotherapy for venous malformations of penile region in children.

METHODS

A total of 9 cases children with penile venous malformations treated by DSA-guided percutaneous sclerotherapy from January 2017 to June 2018 were enrolled in this study. Local angiography was performed under DSA fluoroscopy, and the shape, extent and venous drainage of the tumor nest were judged. Then sclerosing agents (Pingyangmycin and Polidocanol) were selected according to the flow rate of angiography and treated by percutaneous injection under DSA monitoring. Imaging examination (MRI) was performed to evaluate clinical improvement.

RESULTS

A total of 26 interventional sclerotherapy sessions were performed in 9 children, with an average of (2.3±0.5) sessions per case. After a mean follow-up of 7.3 months, 6 cases were cured, and 3 cases were in basic remission. There were 9 cases of temporary edema secondary to the treatment site and 3 cases of mild pain. No serious complications such as ulceration, hemorrhage, infection and dysfunction occurred in any patients.

CONCLUSION

DSA-guided percutaneous sclerotherapy for venous malformations of penile region in children is safe and effective, does not affect the appearance and function of penis, and is worthy of clinical promotion.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

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.

Diagnostic and Therapeutic Ultrasound on Venous and Arterial Ulcers: A Focused Review

GENERAL PURPOSE

To provide information about the use of ultrasound for diagnostic and therapeutic treatment of venous and arterial ulcers.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, you should be able to: ABSTRACT: To review the diagnostic and therapeutic use of ultrasound on venous and arterial ulcers.

METHODS

PubMed was searched for peer-reviewed articles using the search terms "ultrasound for venous ulcers" and "ultrasound for arterial ulcers." The search yielded 282 articles on ultrasound for venous ulcers and 455 articles for ultrasound on arterial ulcers. Data from 36 articles were selected and included after abstract review.

RESULTS

Ultrasound is an established diagnostic modality for venous and arterial disease and is indicated for wound debridement. Recent evidence continues to support its superiority over standard of care in healing venous ulcers, but findings conflict in terms of the effectiveness of low-frequency ultrasound over high-frequency ultrasound. There are currently no standardized treatment protocols for ultrasound.

CONCLUSIONS

Diagnostic ultrasound is used to assess venous and arterial disease and guide appropriate treatment for ulcers. Therapeutic low-frequency ultrasound is used to debride the wound bed, as an adjunctive topical wound treatment with standard of care, and to guide the application of other advanced therapies to chronic wounds. Better trial designs and consistent data are needed to support the effectiveness of ultrasound therapy on venous and arterial ulcers.

Vascular Anomalies of the Head and Neck Region

Vascular anomalies of the head and neck region are a complex group of lesions that challenge the head and neck physicians. From the very understanding of the difference between its two distinct forms, hemangiomas and vascular malformations to its management remain confusing. The review of this anomaly attempts at comprehensively understanding the disease. Vascular anomalies are easily diagnosed by their clinical presentation, but choice of imaging and management for this spectrum of lesions is varied. The author attempts to categorize the required imaging for the lesion with suggestions on the management of both hemangiomas and vascular malformations. The available treatment options are discussed, and a comprehensive algorithm for management is suggested. Further research in developing drugs that could restrict the growth of these lesions would be the future of the management of vascular lesions.

Polidocanol Sclerotherapy Combined with Transarterial Embolization Using n-Butyl Cyanoacrylate for Extracranial Arteriovenous Malformations

Purpose

To assess the safety and effectiveness of polidocanol sclerotherapy combined with transarterial embolization using a liquid adhesive agent (n-butyl cyanoacrylate, NBCA) for treatment of extracranial arteriovenous malformations (AVMs).

Materials and Methods

Twenty-three patients with symptomatic AVMs in the head and neck (6), upper (7) and lower extremity (10) with a mean age of 42 years (range 4–74) treated with polidocanol sclerotherapy were retrospectively assessed. AVMs were classified according to the angiographic morphology of the nidus. There were 2 type I, 6 type II, 6 type IIIa and 9 type IIIb. Arterial embolization using NBCA was performed to reduce arterial flow before sclerotherapy. Polidocanol mixed with contrast material or carbon dioxide was delivered by percutaneous direct puncture.

Results

Treatment was successfully performed in all patients. In the mean follow-up period of 38 months, symptoms resolved or improved in 20/23 patients (87.0%). AVMs were devascularized 100% in 2 patients, 76–99% in 13, 50–75% in 7 and < 50% in 1. More than 50% devascularization was seen in 22 patients (95.6%). Two (8%) patients had complete remission, 17 (74%) had partial remission and 3 (13%) had no remission. There was no aggravation. Treatment was considered effective (complete and partial remission) in 20 patients (87.0%). Minor complications including localized arterial thrombosis (2) and spontaneously healing skin ulcer (1) were seen in 2 patients (8.7%). There were no major procedure-related complications.

Conclusion

Polidocanol sclerotherapy combined with transarterial embolization using NBCA is safe and effective for treating extracranial AVMs with an acceptable risk of minor complications.

Endovascular Management of Venous Malformations

Venous malformations are the most common vascular anomalies. When they are superficial and large, they are easily recognized. However, when the malformation is deep or involves normally occurring veins, the diagnosis can be challenging. Extremity varicosities may be the only visible signs of the problem. Unfortunately, varicosities are often presumed to be the result of superficial venous insufficiency and the underlying venous malformation is overlooked. The phlebologist must be cognizant of the possibility that a venous malformation may be the cause of the patient's symptoms and varicosities. Ultrasound and magnetic resonance imaging can help to confirm the correct diagnosis. Treatment involves image-guided endovenous occlusion of the malformation, most commonly with potent liquid sclerosing agents. Some of these agents can cause severe complications. A thorough knowledge of the sclerosing solutions and the endovascular techniques to properly deliver them to the malformation is essential. This article will review the basic principle surrounding endovascular management of venous malformations.

Indications, contraindications and performance: European Guidelines for Sclerotherapy in Chronic Venous Disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th – 10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the recommendations concerning indications, contraindications, concentrations, volumes and technique of liquid and foam sclerotherapy of varicose veins and venous malformations are reviewed.

Results from RCTs in Sclerotherapy: European Guidelines for Sclerotherapy in Chronic Venous Disorders*

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th–10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the results from recent RCTs in sclerotherapy are reviewed.

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.

Early versus later presentations of venous malformations: where and why?

Venous malformations (VMs) are congenital anomalies of the venous vasculature, but not all are evident at birth. The factors that lead to presentation later in life are not well understood. The objective of this retrospective cohort study of patients with VMs evaluated at the University of California at San Francisco Birthmarks and Vascular Anomalies Center from 2005 to 2009 was to investigate the clinical presentation of VMs and correlate these features with different types of tissues (e.g., skin, subcutis, intramuscular). Main outcomes included the age at which lesions were first noticed, tissue type involved, presenting signs and symptoms, aggravating factors, and morbidities. A total of 115 subjects was included. The mean age when VM was first noted was 6.7 ± 0.9 years. Tissue types involved included skin/subcutaneous (46%); intramuscular (40%); and bone, tendon, or joint (14%). Presenting signs/symptoms included soft tissue swelling (44%), discrete mass (34%), pain (33%), and skin discoloration (26%). When compared with VMs limited to the skin or subcutis, those restricted to the intramuscular compartment were less likely to present at birth (27% vs 53%, p < 0.05) but were more frequently painful (79% vs 60%, p < 0.05) and contained more phleboliths (28% vs 11%, p < 0.05), and were associated with more exercise limitation (35% vs 16%, p < 0.05). VMs differ in age of onset, clinical features, and complications based on differing tissues and sites of involvement, with isolated intramuscular involvement associated with later presentation and greater morbidity.

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.

European guidelines for sclerotherapy in chronic venous disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Sclerotherapy in venous malformation

Venous malformations are the result of an arrested development of the venous system during the embryogenesis. In the treatment of venous malformations the standard of care is a multidisciplinary approach including the use of traditional surgical therapy if applicable and endovascular treatment. Endovascular techniques include embolization therapy for instance with coils but also sclerotherapy with liquid or foamed sclerosants. The aim of this paper is to give an overview of foam sclerotherapy in venous malformations. Sclerotherapy of venous malformations has been performed in superficial and intramuscular malformations. In many cases ethanol has been used for the treatment. Since more than 10 years, less aggressive sclerosants like polidocanol and sodiumtetradecyl sulphate have been used to treat venous malformations. These substances can be used without anaesthesia and the rate of side-effects is much lower. Yamaki and Cabrera are the first who used foam sclerotherapy for the treatment of symptomatic venous malformations. Compared with liquid sclerotherapy foam sclerotherapy has the advantage of a better and longer lasting contact of the sclerosing agent with the vessel wall which leads to a more effective treatment and to a reduction of concentrations needed. In a recent European Guideline on Sclerotherapy foam sclerotherapy is recommended over liquid therapy for the treatment of venous malformations. Foam sclerotherapy is an effective treatment option for low flow extratruncular and truncular venous malformations. Foam is significantly more effective than liquid sclerotherapy and side-effects with polidocanol or sodiumtetradecyl sulphate foam are less compared with sclerotherapy with ethanol. With foam sclerotherapy a significant reduction of pain and volume of the venous malformations can be reached.

Preliminary experience with intraoperative near-infrared fluorescence imaging in percutaneous sclerotherapy of soft-tissue venous malformations

BACKGROUND

It has recently been demonstrated that near-infrared (NIR) fluorescence imaging can be used to visualize the blood vasculature. Although sclerotherapy has been successfully used in treating venous malformations, the spread of sclerosant is difficult to monitor during sclerotherapy.

OBJECTIVE

To evaluate the safety and efficacy of NIR fluorescence imaging in percutaneous sclerotherapy of soft-tissue venous malformations.

METHODS AND MATERIALS

The use of NIR fluorescence imaging after administration of indocyanine green (ICG) was evaluated in duplex-guided sclerotherapy performed on 15 patients with venous malformations. The lower extremities were involved in seven, the upper extremities in four, and the face in four.

RESULTS

In 13 of the 15 procedures, spotty fluorescence images were obtained, and in eight procedures, linear fluorescence images were obtained. In two patients with intramuscular venous malformations in the lower extremities, no fluorescence images were obtained. Observational depth seemed to be <1 cm below the skin surface with an ICG concentration of 0.01 mg/mL. No complications associated with ICG were observed. Adjacent tissue ulceration occurred in one patient.

CONCLUSION

NIR fluorescence imaging with ICG can be a useful additional monitor for percutaneous sclerotherapy of venous malformations, especially in the face and hands, enabling noninvasive assessment of real-time spread of sclerosant.

Prevalence of various congenital vascular malformations in patients with Klippel-Trenaunay syndrome

OBJECTIVE

Klippel-Trenaunay syndrome (KTS) is a condition defined by the association of three physical features: capillary malformation, varicosities, and hypertrophy of bony and soft tissues. However, KTS is characterized by congenital vascular malformations (CVMs) that are difficult to classify. Therefore, the present study was undertaken to analyze the various CVMs in patients with KTS.

METHODS

Sixty-one patients with KTS were enrolled, and their CVMs were divided into predominantly venous defects, predominantly lymphatic defects, and mixed vascular defects using the Hamburg Classification. Capillary malformations were subdivided into port-wine stain, telangiectasia, and angiokeratoma. Truncular and extratruncular vascular malformations were detected using duplex ultrasound and magnetic resonance imaging. Reflux in the superficial and deep venous systems was also evaluated.

RESULTS

Forty-five patients (74%) had predominantly venous defects, four (6%) had predominantly lymphatic defects, and 12 (20%) had mixed vascular defects. Capillary malformations were detected in 54 patients (89%), among which port-wine stain was the most predominant (40 patients, 66%), followed by telangiectasia (31 patients, 51%) and angiokeratoma (18 patients, 30%). Extratruncular venous malformations were detected in 47 patients (77%). In contrast, truncular venous malformations were found in 50 patients (82%). Among these, embryonic lateral marginal vein showed the highest occurrence, accounting for 53% (32 patients). However, reflux in this vein was detected in only nine patients (15%). Twelve patients (20%) had reflux in the great saphenous vein, and four (7%) had reflux in the small saphenous vein. Deep vein hypoplasia was found in seven patients (12%), and only five patients (8%) had deep vein aplasia. Extratruncular lymphatic malformations were found in 13 patients (21%) and truncular lymphatic malformations in 17 (28%).

CONCLUSIONS

Patients with KTS have a variety of CVMs, but both extratruncular and truncular venous malformations continue to be targets for intervention.

Percutaneous sclerotherapy of peripheral venous malformations in pediatric patients

PURPOSE

To report the efficacy of percutaneous puncture and sclerosis using polidocanol in the treatment of venous malformations (VMs) in pediatric patients.

PATIENTS/METHODS

Between March 2007 and February 2011, a series of 19 patients with VMs on the upper and lower extremities had undergone a total of 89 sessions of intralesional sclerotherapy using polidocanol. All the procedures were performed in an angiographic suite under general anesthesia in order to maintain sedation for facilitating the procedure. For each injection, approximately 1 ml of 2% polidocanol was injected for each centimeter of the diameter of the lesion, with a maximum of 6 ml. Injection of the sclerosant was guided by real-time sonography and fluoroscopy.

RESULTS

After the treatment, the symptoms completely resolved in four patients (21%). Clinical symptoms, such as bulging and pain were improved in 12 out of 19 patients (63%). They remained unchanged in three patients (16%). During the procedures, no major complications were encountered. The minor complications (65%) encountered were swelling and pain after treatment which were resolved by taking NSAID within a few days.

CONCLUSION

In pediatric patients, sonographically guided percutaneous puncture and fluoroscopically guided sclerosis using 2% polidocanol is effective, less invasive and safe for the treatment of VMs, with a high success rate and minimal complications.

Management of palatal vascular malformation using absolute ethanol sclerotherapy

Arteriovenous malformation is treated by variety of techniques over the years. Sclerotherapy is considered an effective and conservative technique for the treatment of benign vascular lesions and replaced the traditional role of surgical therapy, especially for the venous lesions that are surgically difficult or at inaccessible areas. Absolute ethanol was adopted as a new sclerosant agent for this complex form of venous defects to improve overall treatment results with acceptable morbidity and recurrence rates. Sclerotherapy has the advantage of no external scaring, low cost, and few complications in comparison to the surgical treatment.

Acute renal failure, microangiopathic haemolytic anemia, and secondary oxalosis in a young female patient

A 29-year old female presented with a one-week history of vomiting, diarrhoea, abdominal pain, and headache. On admission, she had acute renal failure requiring dialysis. Tests revealed a hemolytic anemia with thrombocytopenia. An initial diagnosis of thrombotic thrombocytopenic microangiopathy was made and plasma exchange was instigated. However, renal biopsy did not show thrombotic microangiopathy but instead revealed acute kidney injury with mild tubulointerstitial nephritis and numerous oxalate crystals, predominantly in the distal tubules. The patient had been taking large doses (>1100 mg daily) of vitamin C for many months. She also gave a history of sclerotherapy using injections of an ethylene glycol derivative for superficial leg veins. The patient completed five sessions of plasma exchange and was able to discontinue dialysis. She eventually achieved full renal recovery. She has now discontinued sclerotherapy and vitamin supplementation.

A Step-by-Step Practical Approach to Imaging Diagnosis and Interventional Radiologic Therapy in Vascular Malformations

Within vascular anomalies, vascular malformations are those present at birth that grow with the patient and exhibit abnormal dilated vascular channels lined by mature endothelium. Vascular tumors, the other group of vascular anomalies, demonstrate endothelial hypercellularity. Vascular malformations are further divided into low-flow varieties (capillary, venous, and lymphatic malformations) and high-flow varieties (arteriovenous malformation and fistula). All malformations exhibit a predictable group of clinical patterns that vary in severity and rate of progression. The interventional radiologist must incorporate this clinical data with characteristic ultrasound and magnetic resonance findings to arrive at a diagnosis. One must then decide in a multidisciplinary fashion, based on objective clinical criteria and image-based morphology, if the patent is a candidate for intervention. Sclerotherapy is a technique used to treat vascular malformations whereby an endothelial-cidal agent is introduced into the endoluminal compartment to initiate vascular closure. The high flow rate of an arteriovenous malformation requires the incorporation of superselective transarterial, direct, and transvenous access with flow reduction techniques to deliver adequate dose of sclerosant and embolic to the nidus. Satisfactory outcomes are seen in over half of all malformations patients. Similar treatment-related complications are seen between malformations but are lowest in lymphatic and highest in arteriovenous malformations.

Foam sclerotherapy using polidocanol (aethoxysklerol) for preoperative portal vein embolization in 16 patients

PURPOSE

To evaluate the clinical safety and effectiveness of foam sclerotherapy using polidocanol for preoperative portal vein embolization (PVE) before hemihepatectomy of the liver.

MATERIALS AND METHODS

From March 2006 to October 2008, foam sclerotherapy using polidocanol was performed in 16 patients (male-to-female ratio of 12:4, age range 48-75 years [mean 62]) for PVE. Patients were diagnosed with Klatskin tumor (n = 13), gallbladder (GB) cancer (n = 2), or hepatocellular carcinoma (HCC) (n = 1). The foam was composed of a 1:2:1 ratio of 3% polidocanol (Aethoxysklerol; Kreussler Pharma, Wiesbaden, Germany), room air, and contrast media (Xenetix 350; Guerbet, Aulnay-Sous-Bois, France). The total amount of polidocanol used (2 to 8 mL [mean 4.6]) varied according to the volume of the target portal vein. We calculated the volume of future liver remnant (FLR) before and after PVE and evaluated complications associated with the use of polidocanol foam sclerotherapy for PVE.

RESULTS

Technical success was achieved in all patients. All patients were comfortable throughout the procedure and did not experience pain during sclerotherapy. No periprocedural morbidity or mortality occurred. Patients underwent a liver dynamic computed tomography (CT) scan 2-4 weeks after PVE. FLR increased significantly after PVE using polidocanol foam from 19.3% (range 16-35%) before PVE to 27.8% (range 23-42%) after PVE (p = 0.001). All patients were operable for hemihepatectomy of the liver and achieved effective resection.

CONCLUSION

Foam sclerotherapy using polidocanol is clinically safe and effective for preoperative PVE.

Angiographic Classification and Sclerotic Therapy of Maxillofacial Cavernous Haemangiomas: A Report of 204 Cases

A total of 204 patients with maxillofacial cavernous haemangiomas were examined by digital subtraction angiography to investigate the factors affecting therapeutic outcome and to optimize treatment selection. Cavernous haemangiomas were classified as high-or low-drainage based on the nature of the draining veins. Patients were randomized to receive either embolization of the draining veins with absolute ethanol followed by bleomycin A5 hydrochloride intra-tumoural injection, or intra-tumoural injection only. In patients with high-drainage haemangiomas ( n = 140), there were significant improvements inthe complete cure rate and the overall effective rate in those who had received embolization prior to intra-tumoural injection compared with those who had received intra-tumoural injection only. In patients with low-drainage haemangiomas ( n = 64), there were no significant differences between the two treatment groups. It is concluded that embolotherapy of draining veins prior to hydrochloride injection is effective for treating high-drainage cavernous haemangiomas whereas bleomycin A5 hydrochloride injection alone is suitable for treating low-drainage cavernous haemangiomas.

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.

Ethanol sclerotherapy for the management of craniofacial venous malformations: the interim results

Objective

We wanted to evaluate the safety and feasibility of ethanol sclerotherapy for treating craniofacial venous malformations (CVMs).

Materials and Methods

From May 1998 to April 2007, 87 patients (40 men and 47 women; age range, 2-68 years) with CVMs underwent staged ethanol sclerotherapy (range, 1-21 sessions; median number of sessions, 2) by the direct puncture technique. Clinical follow up (range, 0-120 months; mean follow up, 35 months; median follow up, 28 months) was performed for all the patients. Therapeutic outcomes were established by evaluating the clinical outcome of the signs and symptoms in all patients, as well as the degree of devascularization, which was determined on the follow-up imaging, in 71 patients.

Results

A total of 305 procedures with the use of ethanol were performed in 87 patients. Follow-up imaging studies were performed for 71 of 87 patients. Twenty-three (32%) of the 71 patients showed excellent outcomes, 37 patients (52%) showed good outcomes and 11 patients (16%) showed poor outcomes. Ethanol sclerotherapy was considered effective for 60 patients. All the minor complications such as bulla (n = 5) healed with only wound dressing and observation. Any major complication such as skin necrosis did not develop.

Conclusion

Percutaneous ethanol sclerotherapy is an effective, safe treatment for CVMs.

Venous malformations: classification, development, diagnosis, and interventional radiologic management

Venous malformations are categorized as low-flow vascular malformations within the domain of vascular anomalies and are the most common vascular malformation encountered clinically. Venous malformations are by definition present at birth, undergo pari passu growth, and present clinically because of symptoms related to mass effect or stasis. Although diagnosis can usually be made by clinical history and examination, differentiation from other vascular and nonvascular entities often requires an imaging work-up that includes ultrasound, CT, MR imaging, and diagnostic phlebography. All decisions regarding imaging work-up and decision to treat must be coordinated though referral and discussions with a multidisciplinary team and be based on clearly defined clinical indications. Percutaneous image-guided sclerotherapy has become the mainstay of treatment for venous malformations and involves the introduction of any one of a number of endothelial-cidal sclerosants into the vascular spaces of the lesion, with each sclerosant possessing its own unique spectrum of advantages and disadvantages.

Percutaneous sodium tetradecyl sulfate sclerotherapy for peripheral venous vascular malformations: a single-center experience

PURPOSE

To evaluate the efficacy, safety, and long-term outcomes of percutaneous sodium tetradecyl sulfate (STS)sclerotherapy for peripheral venous vascular malformations (VVMs).

MATERIALS AND METHODS

A retrospective review of a prospectively compiled database was performed to identify patients with a VVM who were referred from 1997 to 2004. Of the 132 patients identified, 78 underwent sclerotherapy. Six of the 78 patients were lost to follow-up. Of the remaining 72 patients (24 male and 48 female patients; mean age, 31.7 years; age range, 14-62 years), 42 (58%) had lower limb VVMs, 19 (26%) had upper limbVVMs, and nine (12%) had truncal and/or central VVMs. Two patients (2.8%) had multifocal lesions. Seven of the 72 patients (9.7%) had Klippel-Trénauney syndrome. Treatment response was assessed clinically and by means of lesion size measurement with magnetic resonance (MR) imaging.

RESULTS

A total of 226 treatment sessions were performed (mean, 3.1 sessions per patient; range, 1-13 sessions). The mean follow-up was 41 months (range, 21-84 months). After treatment, 11 patients (15%) became asymptomatic, 20(28%) rated the response to therapy as good, 17 (24%) improved, 20 (28%) were unchanged, and four (5.6%) worsened.Thirty-five patients underwent MR imaging before and after treatment. The size of the VVM was seen to decrease in19 patients (54%), be unchanged in 11 (31%), and increase in five (14%). A reduction in lesion size at MR imaging did not necessarily correlate with a positive clinical response. Overall, patients with infiltrative lesions had a poorer outcome than did those with localized lesions. There were no major complications and seven minor complications(3.1% per session, 9.7% per patient).

CONCLUSIONS

An improvement in symptoms was observed in 70% of the patients with VVMs treated with percutaneous STS. Although the treatment is safe, complete cure is unusual and multiple treatment sessions are almost always required.

Foam sclerotherapy — A possible option in therapy of varicose veins

The therapy of varicose veins is multimodal and depends on the individual clinical findings. In addition to compression therapy, invasive approaches for elimination of reflux for the treatment of varicose veins are available, such as surgical and interventional methods and sclerotherapy. The administration of a sclerosing agent into a varicose vein results in an occlusion of the treated vein. Recently the use of foam sclerotherapy had a renaissance. Several studies have documented the efficacy of foam sclerotherapy in selected patients. The possibility of treating patients in an outpatient setting, with low costs and rapidly, makes foam sclerotherapy very attractive compared to invasive and minimally invasive methods. However long-term follow-ups in properly controlled randomized trials are needed before foam sclerotherapy can be recommended as a routine procedure. This paper introduces the method and the treatment possibilities with foam sclerotherapy in chronic venous insufficiency.

Nd:YAG lasers (1,064 nm) in the treatment of venous malformations of the face and neck: challenges and benefits

Neodymium:yttrium aluminum garnet (Nd:YAG) laser therapy for venous malformations (VMs) of the head and neck is a rather new therapeutical option in addition to sclerotherapy and surgery. One hundred forty-six patients (age 2 months to 77.5 years) with VMs in the head/neck (localized, diffuse, and multifocal) were retrospectively analyzed with regard to number and quality of treatments and laser parameters used. Of these patients, 72 had no prior treatment of any kind, and 74 were pretreated. Laser treatment of mucosa and tongue was done with a mean fluence of 103.1 J/cm(2), of skin with 90.7 J/cm(2), and of glomuvenous malformations with 81.2 J/cm(2). Complex VM can mostly be controlled but rarely cured. Initial Nd:YAG laser therapy is important in the treatment of VMs regarding shrinkage of the tissue, discoloration, and induction of the desired dermal fibrosis that facilitates the surgical handling of the skin and reduces the risk of skin loss in surgery and sclerotherapy.

Therapeutic choice for craniofacial venous malformations

Even though the precise mechanisms related to venous malformation are still unclear, the clinical manifestations sometimes threaten vital signs such as mastication, airway and phonics. Our therapeutic modalities were reviewed, and their effectiveness and related complications were analyzed. Between March, 1998 and February, 2006, 11 patients (15-59 years old; average 32.4 +/- 13.60, 4 women and 7 men) with craniofacial venous malformation were included in this investigation. All cases experienced some kind of surgery at least once during clinical follow-up. Direct puncture scintigraphy with technetium-99m Sn colloid-labeled demonstrated low-flow malformations in all cases. Two cases underwent bone surgery and another two cases had static suspensions for facial nerve paralysis. Blood loss from surgery alone was 1352 +/- 1115.0 mL, simultaneous procedures yielded 400 +/- 244.9 mL blood loss and sclerotherapy alone resulted in 187 +/- 284.8 mL of blood loss (surgery alone versus sclerotherapy alone, P < 0.01). Excellent sclerotherapy cases were when the malformation was localized and the number of sclerotherapies was significantly fewer than good cases (1.3 +/- 0.58 times versus 3.6 +/- 1.15 times, excellent, good, respectively, P < 0.05). Although there are difficulties in understanding the mechanisms and multiple therapeutic interventions are required, there have been satisfactory outcomes so far and the development of better sclerosants or a real-time navigation system may benefit more precise therapeutic effects and lower morbidity.

Classification, diagnosis, and interventional radiologic management of vascular malformations

Vascular anomalies are comprised of either hemangiomas or vascular malformations.Low-flow vascular malformations can be divided into capillary, venous, and lymphatic types and are usually present at birth, undergo pari passu growth, and produce symptoms related to mass effect or stasis. High-flow malformations are comprised pre-dominantly of arteriovenous malformations that follow a more aggressive clinical course of hyperemia, adjacent mass effect, steal phenomenon, tissue destruction, and ultimately high output failure. Ultrasound, CT, nuclear medicine, angiography, and particularly MRI have greatly enhanced diagnostic accuracy and provide detailed information for percutaneous and surgical treatment planning and an objective means of following therapeutic efficacy. Interventional radiologic percutaneous sclerotherapy for low-flow lesions and embolosclerotherapy for high-flow lesions with or without adjunctive surgical intervention have become the mainstay of therapy.

Peripheral vascular malformations: imaging, treatment approaches, and therapeutic issues

Peripheral vascular malformations are now described according to some accepted guidelines, and the principle of proper treatment (nidus ablation) is becoming clear. An appropriate classification scheme for vascular anomalies and definite indications for treatment are important to successful treatment overall. The findings from noninvasive imaging (ie, Doppler ultrasonography, computed tomography, or magnetic resonance imaging) in association with clinical findings are critical in establishing the diagnosis, evaluating the extent of the malformation, and planning appropriate treatment. Direct opacification of the nidus is useful, not only in making a correct diagnosis, but also in treating the lesion with sclerotherapy. In most cases, conservative treatment is recommended, but when a patient suffers clinical complications (eg, ulceration, pain, hemorrhage, cardiac failure, or unacceptable cosmetic consequences), the nidus sclerotherapy becomes mandatory. If the vascular malformation has blood outflow to a drainage vein during nidus opacification, flow control (with balloon occlusion, tourniquet, or embolization) is necessary to achieve sclerosant stasis within the nidus. Embolotherapy (with a coil, n-butyl cyanoacrylate, or small particles) should be used for subsequent multifaceted palliative therapy. A multi-disciplinary approach is needed in the treatment of a high-flow lesion, and a dedicated team approach is necessary for appropriate management in most cases.

Sklerosierungstherapie der Varikose

Sclerotherapy is a standard treatment for intradermal varicose veins and branch varicosities. In the treatment of insufficient saphenous veins, crossectomy and stripping used to be the methods of choice. In the last few years good results have also been reported for endovenous methods such as endovenous laser and radio frequency treatment. Sclerotherapy is more effective and even appropriate for larger saphenous veins when the sclerosing liquid is replaced by a foam agent. This cost-effective approach can be done on an outpatient basis without additional anesthesia. Prospective randomized studies are need to confirm the effectiveness.

Venous angiomata: treatment with sclerosant foam

Venous angiomata, or venous malformations, are often present at birth, although they may not be evident until later. They consist of a spongy tangle of veins, and these lesions usually vary in size. Treatment of venous angiomata is often requested for cosmetic reasons, but painful ulcerations, nerve compression, functional disability can command care. This presentation describes management using sclerosant foam as the treating agent. During a 30-month period ending March 2004, 1,321 patients were investigated for venous disorders at the Vein Institute of La Jolla. Fourteen (incidence 1%) were found to have venous angiomata (: nine women). The age range was 15-76 years (mean 30.8 +/- 18.6). Lesions were classified by the Hamburg system and were primarily venous, extratruncular in 12 patients and combined extratruncular and truncular in two patients. Eight patients, three males, had manifestations of lower extremity Klippel-Trenaunay (syndrome; six had only venous angiomas. Only 10 of the 14 patients were treated. All patients were studied by Doppler duplex examination. Selected lesions were chosen for helical computed tomographic studies. Magnetic resonance venography was also used to image the lesions, define the deep circulation, note connections with normal circulation, identify vessels for therapeutic access, and determine infiltration of the lesion into adjacent soft tissue. Foam was produced by the Tessari two syringes one three-way stopcock teclinique, with the air to Polidocanol ratio being 4 or 5 to 1. This was used at 1% or 2% concentration, specific for each patient. The SonoSite 190 plus Duplex Doppler was used for ultrasound guidance, whenever deep access was required and to monitor progress and effects of treatment. A goal was set for each patient before treatment was begun. Ten patients were treated, and four await treatment. The mean number of treatments was 3.6 +/- 2.8 (range 1-10). A primary goal of pain-free healing was set in patients with nonhealing, painful ulceration or symptomatic varicose veins. This was achieved in all treated patients. Cosmetically, all of the patients were improved, and symptomatic patients were relieved of pain. The single complication was formation of a cutaneous ulcer following injection of telangiectasias. Sclerosant foam is a satisfactory tool to use in treating venous angiomata including the Klippel-Trenaunay syndrome. Use of foam sclerotherapy in this experience has proven the technique to be effective, essentially pain-free, and durable in the short term.

Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles

OBJECTIVES

Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of veins in the lower limb by ultrasound imaging.

DESIGN

Consensus conference leading to a consensus document.

METHODS

The authors invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the experts were made available to all participants via the UIP website. The authors prepared a draft document for discussion at a UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually all participants agreed the final version of the paper.

RESULTS

The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document suggests a methodology for complete assessment of the superficial and perforating veins of the lower limbs, including recommendations on reporting results and training of personnel involved in these investigations.

CONCLUSIONS

The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonographpy.

Direct percutaneous ethanol instillation for treatment of venous malformation in the face and neck

Venous malformations of the face and neck involve multiple anatomical spaces and encase critical neuromuscular structures, making surgical treatment difficult; high recurrence rates and high morbidity are well documented. Various methods of treatment of uncertain value and risk of complications have been advocated. We present our experience in treating five patients with venous malformation in the face and neck by using direct percutaneous ethanol sclerotherapy. Four patients had large lesions (> or = 3 cm; one patient had two large lesions in the low eyelid), and the other had a mid-sized lesion (1.5-3 cm). Under general or local anaesthesia, one-third to one-quarter cavity volume of ethanol was injected percutaneously, directly into the malformation with under fluoroscopy [de Lorimier AA. Sclerotherapy for venous malformations. J Pediatr Surg 1995;30:188-93; Johnson PL, Eckard DA, Brecheisen MA, Girod DA, Tsue TT. Percutaneous ethanol sclerotherapy of venous malformations of the tongue. Am J Neuroradiol 2002;23:779-82; Pappas DC Jr, Persky MS, Berenstein A. Evaluation and treatment of head and neck venous vascular malformations. Ear Nose Throat J 1998;77:914-22; Lee CH, Chen SG. Direct percutaneous ethanol sclerotherapy for treatment of a recurrent venous malformation in the periorbital region. ANZ J Surg. 2004;74(12):1126-7.]. Four patients required two injections. All patients had remission and alleviation of their symptoms, with no major complications. Direct percutaneous injection of absolute ethanol provides a simple and reliable alternative treatment for venous malformation in the face and neck.

Guidelines for sclerotherapy of varicose veins (ICD 10: I83.0, I83.1, I83.2, and I83.9)

BACKGROUND

Sclerotherapy is the targeted elimination of intracutaneous, subcutaneous, and/or transfascial varicose veins (perforating veins) as well as the sclerosation of subfascial varicose vessels in the case of venous malformation by the injection of a sclerosant. With duplex-guide sclerotherapy and foam sclerotherapy, modified methods came into use.

OBJECTIVE

The objective was to create a guideline, based on the available publications and on the European Consensus Document on foam sclerotherapy from April 2003.

METHODS

This guideline was drafted on behalf of the German Society of Phlebology (Deutsche Gesellschaft für Phlebologie) and adopted by the committee and scientific advisory board of the Deutsche Gesellschaft für Phlebologie on June 15, 2001, and amended on December 5, 2003. The guideline considers the present state of knowledge as reflected in the literature.

CONCLUSIONS

This guideline represents the recent state of the art of sclerotherapy of varicose veins in Germany including foam sclerotherapy.