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Hu S, Muss TE, Toyoda Y, Kim MS, Chang AE, Banala M, Graham EM, Gunturi D, Lin IC. Surgical Management of Vascular Malformations of the Upper Extremity: A 12-Year Retrospective Cohort Study. Ann Plast Surg 2024; 92:S132-S135. [PMID: 38556661 DOI: 10.1097/sap.0000000000003852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Vascular malformations (VMs) typically appear at birth and grow commensurately with patients. They can vary broadly in vessel type and tissue involvement, and upper extremity (UE) VMs can pose unique functional and aesthetic challenges in children. Given the advent of operative and nonoperative technologies like sclerotherapy and medications, a contemporary review of the surgical management of UE VMs is warranted. METHODS We performed a retrospective review of all patients who had surgical management of VMs from 2010 to 2021 at The Children's Hospital of Philadelphia. Demographics, lesion characteristics, treatment (including preceding nonsurgical therapies), complications, and final outcomes were recorded. Operative notes were reviewed for date of operation, depth of excision, type of closure, and current procedural terminology code. RESULTS Sixty-seven patients with 88 procedures were studied. Average patient age was 5.8 years, with 64% White and 67% male. Venous (34%) and lymphatic (19%) malformations were most common, and anatomic locations were most frequently on the hand (33%) and forearm (25%). The average lesion diameter was 4.2 cm, although this varied by location (eg, 2.9 cm, hand; 11.1 cm, chest wall). Fifty-eight patients (87%) underwent surgical excision as their index procedure, and 9 had sclerotherapy before surgery. Thirty-nine patients (60%) had subcutaneous excisions, and the remainder required subfascial or intramuscular excisions. Nearly all excisions were closed primarily (97%). Of the 53 patients with documented follow-up, 32 patients (60%) had complete resolution of their lesion as of their final visit. Thirty of these 32 patients with no clinical evidence of residual VM had only 1 surgery for excision. CONCLUSION Upper extremity VMs were composed of diverse conditions with varying vessel types, size, depth, and anatomic sites. Surgical excision of VMs of the UE was safe and effective. A majority of VMs were fully excised after 1 procedure and frequently closed primarily with relatively low complication rates. Future work should investigate decision-making and outcomes of all treatment options of VMs of the UE for optimal functionality and aesthetics.
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Affiliation(s)
- Sophia Hu
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Tessa E Muss
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Yoshiko Toyoda
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Mimi S Kim
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Ashley E Chang
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Manisha Banala
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Emily M Graham
- Department of Plastic Surgery, University of Michigan, Ann Arbor, MI
| | - Deepthi Gunturi
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ines C Lin
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Cao J, Liu J, Zhang X, Wang Z. A systematic review and network meta-analysis of the effectiveness of sclerotherapy for venous malformation. J Vasc Surg Venous Lymphat Disord 2023; 11:210-218.e3. [PMID: 36179784 DOI: 10.1016/j.jvsv.2022.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 07/24/2022] [Accepted: 08/02/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Sclerotherapy for venous malformation has been widely used; however, no guidelines are available to assess the effectiveness of different sclerotherapy agents. We conducted a systematic review and network meta-analysis to investigate the effectiveness of sclerotherapy agents for venous malformations. METHODS Three electronic databases were searched from their inception (1950) to April 29, 2021. Studies comparing the effectiveness of different sclerotherapy agents were included. The risk of bias within and across studies was assessed. Pairwise meta-analyses were conducted, followed by a network meta-analysis. We also assessed inconsistency and publishing bias using various approaches. RESULTS Seven studies with 547 patients in six arms were included in the present study. We defined the response and complete response as two separate outcomes. Significant differences were observed in four comparisons with respect to the response (ethanol vs bleomycin, ethanol vs polidocanol, ethanol vs sodium tetradecyl sulfate, polidocanol vs sodium tetradecyl sulfate). No statistically significant differences were found in the other comparisons. The evidence network revealed that for the response outcome, ethanol ranked first, followed by pingyangmycin, polidocanol, sodium morrhuate, bleomycin, and, finally, sodium tetradecyl sulfate. For the complete response outcome, pingyangmycin had the best results, followed by sodium morrhuate, polidocanol, ethanol, bleomycin, and, finally, sodium tetradecyl sulfate. Major complications, such as facial nerve palsy, serious local swelling, and necrosis, had occurred mostly in the ethanol group and rarely in the other groups. Because of the limited data, no further analysis of major complications was conducted. Our confidence in the comparisons and rankings was low. We found no verified inconsistency or publishing bias in the present study using the existing approaches. CONCLUSIONS Ethanol showed a significantly better response statistically compared with the other agents. However, ethanol had also resulted in the highest incidence of complications. Pingyangmycin showed the second-best response, best complete response, and a low rate of complications, respectively. Overall, pingyangmycin achieved excellent performance and balance in terms of the different outcomes. However, they could not be adequately recommended from the available data. More superior trials, especially randomized controlled trials, are needed in the future.
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Affiliation(s)
- Jiajie Cao
- Department of Stomatology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jiajing Liu
- Research Institute of General Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Xinyue Zhang
- Department of Stomatology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhiming Wang
- Department of Stomatology, Shengjing Hospital of China Medical University, Shenyang, China.
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Long-Term Outcome of Single-Session, Ultrasound-Guided, Radiofrequency Ablation for Symptomatic Small, Lower Limb, Venous Malformations. J Belg Soc Radiol 2022; 106:68. [PMID: 35891680 PMCID: PMC9284999 DOI: 10.5334/jbsr.2801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/21/2022] [Indexed: 11/20/2022] Open
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Kocher M, Yilmaz S, Visoiu M. Sciatic nerve neuropraxia following embolization therapy in a patient receiving quadratus lumborum nerve block. J Clin Anesth 2021; 78:110601. [PMID: 34862086 DOI: 10.1016/j.jclinane.2021.110601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Matthew Kocher
- UPMC Children's Hospital of Pittsburgh, Department of Anesthesiology and Perioperative Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Sabri Yilmaz
- Division of Pediatric Interventional Radiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Mihaela Visoiu
- UPMC Children's Hospital of Pittsburgh, Department of Anesthesiology and Perioperative Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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Bernhard SM, Tuleja A, Laine JE, Haupt F, Häberli D, Hügel U, Rössler J, Schindewolf M, Baumgartner I. Clinical presentation of simple and combined or syndromic arteriovenous malformations. J Vasc Surg Venous Lymphat Disord 2021; 10:705-712. [PMID: 34649003 DOI: 10.1016/j.jvsv.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/03/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Arteriovenous malformations of the lower extremities (AVMLE) can present as simple or complex combined or syndromic forms (eg, Parkes Weber Syndrome). We aimed to characterize the differences in clinical presentation and natural history of these potentially life- and limb-threatening congenital vascular malformations. METHODS We conducted a retrospective analysis of a consecutive series of patients with AVMLE who presented to a tertiary referral center in Switzerland between 2008 and 2018. Clinical baseline characteristics, D-dimer level, and course were summarized and differences between simple, non-syndromic and combined or syndromic AVMLE determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. RESULTS Overall, 506 patients were prospectively enrolled in the Bernese Congenital Vascular Malformation Registry, 31 (6%) with AVMLE. There were 16 women and 15 men, with a mean age of 18 years at first diagnosis (range, 1 month to 72 years). Simple AVMLE was present in 22 (71%) and combined or syndromic AVMLE with limb overgrowth in 9 patients (29%), respectively. Common symptoms and signs were pain (n = 25; 81%), swelling (n = 21; 68%), and soft tissue hypertrophy (n = 13; 42%). Among combined or syndromic patients, three patients died from wound infection with sepsis or disseminated intravascular coagulation with bleeding complications (intracranial hemorrhage and bleeding from extensive leg ulcers). Combined or syndromic patients presented more often with bleeding (67% vs 5%; P < .001), malformation-related infection (44% vs 5%; P = .017) and leg length difference (56% vs 14%; P = .049). D-dimer levels were elevated (mean, 17,256 μg/L; range, 1557-80,000 μg/L) and angiographic appearance showed complex, mixed type of AVMs, including interstitial type IV, in all patients with combined or syndromic AVMLE. CONCLUSIONS Patients with congenital simple AVMLE most often present with benign clinical features and rarely with complications related to hemodynamic changes. Patients with combined or syndromic AVMLE often face serious outcomes dominated by complications other than direct high-flow-related heart failure.
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Affiliation(s)
- Sarah M Bernhard
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aleksandra Tuleja
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jessica E Laine
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Fabian Haupt
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dario Häberli
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ulrike Hügel
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jochen Rössler
- Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Schindewolf
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Smith H, Lim CS, Evans N, Papadopoulou A, Khalifa M, Tsui J, Hamilton G, Brookes J. Incidence of major complications from embolo-sclerotherapy of head and neck vascular malformations in a single specialist centre. Vascular 2021; 30:952-959. [PMID: 34311627 DOI: 10.1177/17085381211035279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Current data on the nature and rate of major complications for embolo-sclerotherapy (EST) of vascular malformations are scarce. However, even fewer studies focus on vascular malformations specific to the head and neck, which confer an increased specific risk of airway compromise, neurologic and ophthalmologic injury. More understanding is required surrounding the type and incidence of complications to improve treatment planning and informed consent. Therefore, this study aimed to review major complications secondary to EST of head and neck vascular malformations over a 5-year period in a single specialized multidisciplinary centre for vascular anomalies. METHODS All interventions were decided by the multidisciplinary team. Demographic, procedural and complication data between 1st January 2013 and 31st December 2017 were prospectively documented in a dedicated database and analysed. EST of high-flow vascular malformations (HFVMs) was performed by selective catheter angiography or direct injection, and by direct injection only for low-flow vascular malformations (LFVMs). Major complications were defined as any tissue or functional damage caused by direct injection, distal embolization or tissue reaction and were decided by the multidisciplinary team. RESULTS Forty-eight patients (median age of 35 years; range of 14-70 years; 18 men and 30 women) had 100 EST procedures for head and neck vascular malformation. Of these, 14 patients had EST for HFVM and 34 patients for LFVM, total 43 and 57 procedures, respectively. Overall, five patients with HFVM developed major complications from EST when compared with two patients with LFVM (p = 0.0167). Two patients required pre-emptive tracheostomy due to risk of post-operative airway compromise. Overall, seven (14.6%) patients experienced major complication from EST. In the HFVM group, major complications from EST occurred in five patients; four cases of tissue ulceration and necrosis (two needed debridement, one healed with resultant fibrosis that impeded speech and one resolved spontaneously) and one post-procedural airway compromise requiring tracheostomy. Meanwhile, in the LFVM group, major complications occurred in two patients; one case of severe necrosis involving the alar cartilage, lip and cheek requiring debridement and reconstruction under plastics and one simple cellulitis. No patients sustained stroke or vision impairment. CONCLUSIONS EST is relatively safe for head and neck vascular malformations in a high-volume experienced centre. Our major complication rate of 14.6% per patient (35.7% for HFVM; 5.9% for LFVM) or 7% per procedure (11.6% for HFVM; 3.5% LFVM) compares favourably with published data from other centres. These data will improve treatment planning and informed consent for EST for both HFVM and LFVM of the head and neck.
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Affiliation(s)
- Helena Smith
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Chung Sim Lim
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, UK.,Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, UK.,National Institute for Health Research, UCLH Biomedical Research Center, London, UK
| | - Nicholas Evans
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Anthie Papadopoulou
- Department of Interventional Radiology, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Mohamed Khalifa
- Department of Interventional Radiology, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Janice Tsui
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, UK.,Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, UK.,National Institute for Health Research, UCLH Biomedical Research Center, London, UK
| | - George Hamilton
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, UK.,Department of Surgical Biotechnology, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, UK
| | - Jocelyn Brookes
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, UK.,Department of Interventional Radiology, 4965Royal Free London NHS Foundation Trust, London, UK
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Sundararajan SH, Ranganathan S, Shellikeri S, Srinivasan A, Low DW, Pukenas B, Hurst R, Cahill AM. Balloon occlusion as an adjunctive technique during sclerotherapy of Puig's classified advanced venous malformations. Phlebology 2021; 36:731-740. [PMID: 33983079 DOI: 10.1177/02683555211015565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Puig types 2 through 4 venous malformations (VMs) are challenging to treat with sclerotherapy given their robust systemic outflow. Endovenous balloon occlusion offers a means of temporarily occluding systemic venous outflow to allow for more complete sclerotherapy. This study reviews our experience of implementing this technique in patients with Puig advanced (types 2 through 4) VMs. METHODS An IRB approved review of treated venous malformations from 2013-2016 revealed 10 patients fitting inclusion criteria. Patient demographics, pre-procedural imaging, intra-procedural technical parameters, and post-procedural follow-up outcomes were recorded. All patients underwent temporary balloon occlusion of a systemic or major draining vein during sclerotherapy. Embolic agents included n-butyl cyanoacrylate glue, sodium tetradecyl sulfate foam, and coils. Standard 5 French angioplasty balloons ranged from 4 to 8 mm diameter and 2 to 8 cm length depending on vessel requiring occlusion. All patients underwent minimum 3-year follow-up questionnaire administration re-assessing resolution of lesion symptomology and post-procedural quality of life (QoL) measures. RESULTS Of the 10 VMs treated, 2 were Type 2, 6 were Type 3, and 2 were Type 4. More than one sclerotherapy session was required in 7/10 patients (mean: 2, range: 1-4). Most common sites of VM systemic drainage included subclavian, popliteal, internal/external jugular, and basilic veins. All patients had no indication for further sclerotherapy following adjunctive balloon occlusion. No non-target embolization or immediate post-procedural complications occurred. Follow-up questionnaires (mean interval: 3 years 6 months, range: 3 years-3 years 11 months) confirmed the persistence of embolization effects, improved QoL, and no additional sclerotherapy sessions for all patients in the cohort. CONCLUSIONS Endovenous balloon occlusion as an adjunct to sclerotherapy can be considered when treating patients with types 2-4 venous malformations. This technique lowers the risk of non-target systemic venous embolization, allowing for operator-driven deeper intralesional sclerosant penetration and subsequently maintained treatment efficacy.
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Affiliation(s)
- Sri Hari Sundararajan
- Department of Neurosurgery, New York Presbyterian Hospital Weill Cornell Medicine, New York, NY, USA
| | | | - Sphoorti Shellikeri
- Department of Radiology, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
| | - Abhay Srinivasan
- Department of Radiology, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
| | - David W Low
- Department of Surgery, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
| | - Bryan Pukenas
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Hurst
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
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Danahey J, Seip R, Lee B, Nassiri N, Dardik A, Guzman R, Nassiri N. Imaging of vascular malformations with a high-intensity focused ultrasound probe for treatment planning. J Vasc Surg Venous Lymphat Disord 2021; 9:1467-1472.e2. [PMID: 33838310 DOI: 10.1016/j.jvsv.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/19/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We aimed to investigate whether a current commercially available high-intensity focused ultrasound (HIFU) probe can adequately image targeted vascular malformations (VMs) in anticipation of HIFU treatment planning and delivery. METHODS We enrolled 10 consecutive patients who were scheduled to undergo treatment of symptomatic peripheral VMs confirmed by routine preoperative contrast-enhanced magnetic resonance imaging and soft tissue duplex ultrasound. The lesions were situated no more than 6 cm from the skin. After induction of general anesthesia and before surgical intervention, we prepared and positioned the Sonablate HIFU probe (SonaCare Medical, LLC, Charlotte, NC) to obtain multiple B-mode images of the targeted VM in the transverse and longitudinal dimensions. We then rated the quality of the images and the feasibility of the imaging process itself using a previously devised questionnaire aimed at evaluating the adequacy of the images for potential HIFU treatment planning and delivery. The patients subsequently underwent surgical intervention and clinical follow-up for their VM per the standard protocol. RESULTS The study included 10 participants aged 21 to 67 years (mean ± standard deviation, 36.5 ± 16.5 years). Six patients (60%) identified as female. The VMs imaged consisted of eight venous (80%), one lymphatic (10%), and one combined lymphovenous (10%) malformation. The lesions were in the extremities only (50%), trunk only (20%), trunk and extremities (20%), or neck and extremities (10%). Pain related to the VM was present in all 10 patients (100%). In all 10 patients, the boundary and location of the VM could be visualized via the HIFU probe despite the diminished B-mode imaging resolution. The absence of Doppler functionality in the HIFU probe did not prevent the identification of the VMs in any patient up to a depth of 6 cm. The results from the postimaging survey showed that difficulty in preparing the study device for imaging was 1.1 ± 0.3 and difficulty in use was 1.1 ± 0.1, with a score of 1 equal to easy and 5 to difficult. The stability of the acoustic coupling to the patient was 1.3 ± 0.2, with a score of 1 representing very stable. CONCLUSIONS We were able to ultrasonically identify and outline all targeted peripheral VMs using a commercially available HIFU probe in anticipation of treatment planning and delivery. Baseline magnetic resonance imaging and soft tissue duplex ultrasound remain essential tools for guiding probe placement and HIFU imaging.
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Affiliation(s)
- James Danahey
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Ralf Seip
- SonaCare Medical, LLC, Charlotte, NC
| | - Brian Lee
- SonaCare Medical, LLC, Charlotte, NC
| | - Nima Nassiri
- Institute of Urology, University of Southern California, Los Angeles, Calif
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Raul Guzman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn; Vascular Malformations Program, Yale New Haven Hospital, New Haven, Conn.
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Embolization of peripheral arteriovenous malformations and fistulas with precipitating hydrophobic injectable liquid (PHIL ®). Radiol Med 2020; 126:474-483. [PMID: 32889705 DOI: 10.1007/s11547-020-01274-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE This paper reports on the preliminary experience of a single center in the embolization of peripheral AVMs and fistulas with precipitating hydrophobic injectable liquid (PHIL®), focusing on technical aspects and short-term clinical outcomes. MATERIALS AND METHODS Seven males and five females were included in this study, mean age 42.16 years. For ten of them, it was the first embolization treatment; two had been previously treated with Onyx® embolization. PHIL® was injected with a transarterial approach without other embolics during the same procedure. Lesions were localized in small bowel (1), colon (1), head face (5), forefoot (1), uterus (1) and thorax (3); all were symptomatic. After 30-day clinical follow-up, a contrast-enhanced CT or MR was acquired at 3 months from intervention to detect eventual lesion residual. RESULTS After a single embolization procedure, complete technical success was obtained in 50%, while clinical improvement without additional therapies was appreciable in all patients. No technical failure occurred; in two cases, a small amount of PHIL® proximally refluxed in nontarget vessels without clinical effects. No tattooing effects of superficial lesions neither artifacts at CT and cone-beam CT controls were evident. CONCLUSIONS PHIL® seems to be a safe and effective liquid embolic agent for the treatment of peripheral AVMs and fistulas; although a direct comparison between PHIL and Onyx was not performed, PHIL might present the advantages of reduced artifacts at postprocedural CT scan and no need for shaking time preparation, but it is more expensive due to lower volume of product for each package and slightly less radiopaque at fluoroscopy.
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Qualitative study of patients with venous malformations: symptom experiences and content validity of patient-reported outcome measures. Qual Life Res 2020; 29:1707-1719. [PMID: 32020564 DOI: 10.1007/s11136-020-02435-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine important symptoms and functional effects of venous malformations (VMs) to assess the content validity of commonly used patient-reported outcome (PRO) measures for use with VM patients. METHODS This cross-sectional, qualitative study involved cognitive interviews with participants with VM aged ≥ 14 years. From February to June 2016, 11 participants (8 female) with a mean (± standard deviation) age of 31 ± 15 years were recruited from three clinical sites. The following subgroups were evaluated: 5 adults (aged ≥ 18) with trunk/extremity VMs; 3 adolescents (aged 14-17) with trunk/extremity VMs; and 3 adults with head/neck VMs. We evaluated the content validity of the Worst Pain Numeric Rating Scale (NRS), Patient-Reported Outcomes Measurement Information System (PROMIS®) Pain Interference 8-item short form, and PROMIS Physical Function 8-item short form. RESULTS The most common participant-reported VM symptoms were swelling (n = 10), skin discoloration (n = 8), acute episodic pain (n = 8), chronic pain (n = 7), numbness (n = 7), and tingling/burning (n = 6). Participants reported that VMs affected their physical function (n = 10), appearance (n = 10), relationships/social activities (n = 7), and emotional health (n = 3). The Worst Pain NRS and PROMIS Pain Interference measures were relevant to all participants' VM experience. Only adults with head/neck VMs found the PROMIS Physical Function measure to be irrelevant. The assessed PRO measures did not address several symptoms commonly reported by VM patients (swelling, skin discoloration, numbness, and appearance). CONCLUSION These results suggest that several VM symptoms are not assessed fully by commonly used PRO measures, and that the relevance of functional limitation questions may vary by VM location.
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Grieb D, Meila D, Greling B, Jacobs C, Hechtner M, Schlunz-Hendann M, Brassel F. Craniofacial venous malformations treated by percutaneous sclerotherapy using polidocanol: a single-center experience. Acta Radiol 2019; 60:593-601. [PMID: 30111191 DOI: 10.1177/0284185118795326] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Percutaneous therapy with various sclerosants is an established treatment of venous malformations in general. We investigated the safety and effectiveness of polidocanol in the craniofacial region. PURPOSE To present and evaluate our subjective and objective mid- and long-term results of patients with craniofacial venous malformations (CFVM) after percutaneous sclerotherapy using polidocanol. MATERIAL AND METHODS Twenty patients with CFVM treated by percutaneous sclerotherapy were followed up and asked to fill in a questionnaire comparing levels of the following CFVM-related symptoms before and after treatment: pain; functional impairment; cosmetic deformities; and impairment in daily life. Additionally, both size reduction as well as procedural-related complication rates were analyzed. RESULTS Evaluation of the questionnaire revealed an improvement or complete relief of CFVM-related symptoms with significant reduced impairment in daily life after percutaneous sclerotherapy. Eighteen (90%) patients noticed a post-sclerotherapy improvement of at least one of their corresponding symptoms and expressed satisfaction with regard to their treatment. For 13 patients, a > 50% size reduction of the CFVM could be observed, while seven exhibited a < 50% size reduction. One minor complication was encountered in 56 treatment sessions (1.8%). CONCLUSION Percutaneous sclerotherapy using polidocanol is a well-tolerated treatment for CFVM with a low complication rate. Size reduction and positive results with improvement of different clinical symptoms can be achieved.
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Affiliation(s)
- Dominik Grieb
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
| | - Dan Meila
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
- Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Hannover, Germany
| | - Bjoern Greling
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
| | - Collin Jacobs
- Department of Orthodontics, University of Mainz, Mainz, Germany
| | - Marlene Hechtner
- Department of Medical Biostatistics, Epidemiology and Informatics, University of Mainz, Mainz, Germany
| | | | - Friedhelm Brassel
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
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Treatment of Head and Neck Arteriovenous Malformations Involving the Facial Nerve. Ann Plast Surg 2018; 81:S44-S53. [DOI: 10.1097/sap.0000000000001494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Transarterial embolization of peripheral high-flow arteriovenous malformation with ethylene vinyl alcohol copolymer (Onyx®): single-center 10-year experience. Radiol Med 2018; 124:154-162. [DOI: 10.1007/s11547-018-0948-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 10/15/2018] [Indexed: 11/27/2022]
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Chewning RH, Monroe EJ, Lindberg A, Koo KSH, Ghodke BV, Gow KW, Javid PJ, Jinguji TM, Perkins JA, Shivaram GM. Combined glue embolization and excision for the treatment of venous malformations. CVIR Endovasc 2018; 1:22. [PMID: 30652153 PMCID: PMC6319524 DOI: 10.1186/s42155-018-0028-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 09/10/2018] [Indexed: 11/19/2022] Open
Abstract
Background The purpose of this study was to evaluate safety, technical success, and clinical outcomes of treatment for venous malformations using n-BCA glue embolization immediately prior to excision. Sixty three patients (22 male, 41 female; mean age 12 years (range 1–25)) who underwent 70 procedures for extremity and trunk venous malformations were reviewed. Indications for treatment included pain (100%), swelling (22%), and diminished range of motion (16%). Thirty seven patients (59%) had undergone prior stand-alone interventional or surgical treatment but were persistently symptomatic. Safety, technical and clinical success were retrospectively assessed. Results Embolization was technically successful in 100% of patients. Mean lesion size was 3.0 × 2.9 × 5.7 cm. Three patients (5%) underwent planned, second stage procedures for lesions intentionally not treated at the first procedure. Four patients (6%) underwent an unplanned, second stage procedure for residual disease after the primary operation. Mean and median follow-up duration were 18 and 17 months, respectively (range 3 to 35 months). Symptomatic improvement was achieved in 58 patients (92%), of whom 41 (65%) reported complete elimination of pain. There were no recognized instances of nontarget embolization or other complications of the interventional procedure. One patient required additional surgery for wound dehiscence and one patient developed an abscess requiring incision and drainage. Minor surgical complications included surgical site skin infections (n = 5) and numbness (n = 1). Mean and median surgical blood loss volumes were 131 mL and 10 mL, respectively. One patient required perioperative blood transfusion. Conclusions Extremity and truncal venous malformations can be safely and effectively treated in a single-stage fashion using glue embolization immediately preceding excision.
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Affiliation(s)
- Rush H Chewning
- 1Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Eric J Monroe
- 1Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Antoinette Lindberg
- 2Department of Orthopedics and Sports Medicine, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Kevin S H Koo
- 1Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Basavaraj V Ghodke
- 1Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Kenneth W Gow
- 3Department of Surgery, Division of General and Thoracic Surgery, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Patrick J Javid
- 3Department of Surgery, Division of General and Thoracic Surgery, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Thomas M Jinguji
- 2Department of Orthopedics and Sports Medicine, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Jonathan A Perkins
- 4Department of Surgery, Division of Otolaryngology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA
| | - Giridhar M Shivaram
- 1Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington USA.,5Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, MA.7.220, PO Box 5371, Seattle, Washington USA
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Ghanouni P, Kishore S, Lungren MP, Bitton R, Chan L, Avedian R, Bazzocchi A, Butts Pauly K, Napoli A, Hovsepian DM. Treatment of Low-Flow Vascular Malformations of the Extremities Using MR-Guided High Intensity Focused Ultrasound: Preliminary Experience. J Vasc Interv Radiol 2018; 28:1739-1744. [PMID: 29157478 DOI: 10.1016/j.jvir.2017.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/29/2017] [Accepted: 06/02/2017] [Indexed: 10/18/2022] Open
Abstract
Five patients with painful vascular malformations of the extremities that were refractory to standard treatment and were confirmed as low-flow malformations on dynamic contrast-enhanced magnetic resonance (MR) imaging were treated with MR imaging-guided high intensity focused ultrasound. Daily maximum numeric rating scale scores for pain improved from 8.4 ± 1.5 to 1.6 ± 2.2 (P = .004) at a median follow-up of 9 months (range, 4-36 mo). The size of the vascular malformations decreased on follow-up MR imaging (median enhancing volume, 8.2 mL [0.7-10.1 mL] before treatment; 0 mL [0-2.3 mL] after treatment; P = .018) at a median follow-up of 5 months (range, 3-36 mo). No complications occurred.
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Affiliation(s)
- Pejman Ghanouni
- Department of Radiology, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488.
| | - Sirish Kishore
- Department of Radiology, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488
| | - Matthew P Lungren
- Department of Radiology, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488
| | - Rachelle Bitton
- Department of Radiology, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488
| | - Lauren Chan
- Department of Radiology, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488
| | - Raffi Avedian
- Department of Orthopedic Surgery, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488
| | - Alberto Bazzocchi
- Department of Diagnostic and Interventional Radiology, Rizzoli Institute, Bologna, Italy
| | - Kim Butts Pauly
- Department of Radiology, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488
| | | | - David M Hovsepian
- Department of Radiology, Stanford University, Richard M. Lucas Center for Imaging, 1201 Welch Rd., Stanford, CA 94305-5488
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Stepanov IV, Olshanskiy MS, Kharitonov DY, Stepanova ES. [Surgical treatment of patients with arteriovenous head and neck angiodisplasia]. STOMATOLOGIIA 2017; 96:28-31. [PMID: 28858276 DOI: 10.17116/stomat201796428-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The aim of the study was to assess the results of surgical treatment in 74 patients with extensive arteriovenous angiodisplasia in the head and neck area. All patients underwent complex examination including ultrasound, CT and MRI with contrast and selective carotid angiography. The lesions excision was performed after endovascular embolization and soft tissue defects were restored by various methods selected according to prevalent vascular lesion type (arterial, arteriovenous, venous, capillary) and blood flow values (high flow, low flow, mixed). Good and satisfactory esthetic results were seen in 95.2% of cases, lesion relapse was detected in 4.8% of cases by 12-18 months follow-up. Endovascular embolization proved to decrease the intraoperative bleeding risk, prevent lesion relapse and minimize the size of the lesion improving the results of radical treatment. Local flap reconstruction usually results in good esthetic results. By local soft tissue deficiency distant free flaps or microsurgical complex flaps may be used.
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Affiliation(s)
- I V Stepanov
- Voronezh State Medical University, Voronezh, Russia
| | - M S Olshanskiy
- Voronezh Regional Clinical Oncology Center, Voronezh, Russia
| | | | - E S Stepanova
- Head Office of Medical and Social Expertize of the Voronezh Region, Voronezh, Russia
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Langbroek GB, Horbach SE, van der Vleuten CJ, Ubbink DT, van der Horst CM. Compression therapy for congenital low-flow vascular malformations of the extremities: A systematic review. Phlebology 2016; 33:5-13. [PMID: 28429627 DOI: 10.1177/0268355516684694] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Ginger B Langbroek
- 1 Department of Plastic, Reconstructive and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Sophie Er Horbach
- 1 Department of Plastic, Reconstructive and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Dirk T Ubbink
- 3 Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Chantal Mam van der Horst
- 1 Department of Plastic, Reconstructive and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Meila D, Grieb D, Greling B, Melber K, Jacobs C, Hechtner M, Schmitz T, Schlunz-Hendann M, Lanfermann H, Brassel F. Endovascular treatment of head and neck arteriovenous malformations: long-term angiographic and quality of life results. J Neurointerv Surg 2016; 9:860-866. [DOI: 10.1136/neurintsurg-2016-012570] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 08/02/2016] [Accepted: 08/05/2016] [Indexed: 01/12/2023]
Abstract
AimTo present the long-term angiographic and subjective results of patients with head and neck arteriovenous malformations (HNAVMs) after endovascular treatment.MethodsWe retrospectively analyzed the medical files of 14 patients with HNAVM who were treated between 2000 and 2014. The treatment of choice was a transarterial superselective microcatheter-based approach followed by embolization using liquid embolic agents. The patients were asked to answer a quality of life questionnaire about the following symptoms before and after treatment: pain, functional impairment, cosmetic deformity, impairment in daily life, and bleeding.ResultsComplete or >90% closure of the AVM was achieved in 6 of 14 patients (43%). >50% shunt reduction was achieved in 10 patients (71%). Three complications were encountered in a total of 86 interventional procedures. Six patients presented with bleeding which was cured in all cases (100%). Four of the 14 patients (29%) specified pain which was resolved in two of them. Another six patients (43%) presented with functional impairment; four were cured and two noted an improvement. All 14 patients presented with cosmetic concerns; four were cured and eight experienced a clearly visible improvement. Nine of 13 patients (69%) presented with impairment in daily life which was resolved in five patients and four reported an improvement.ConclusionsEndovascular embolization is a well-tolerated therapy for HNAVM with a low complication rate. Good angiographic results, positive subjective results, and improvement in different aspects of quality of life can be achieved.
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Aronniemi J, Castrén E, Lappalainen K, Vuola P, Salminen P, Pitkäranta A, Pekkola J. Sclerotherapy complications of peripheral venous malformations. Phlebology 2016; 31:712-722. [PMID: 26494223 DOI: 10.1177/0268355515613740] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Johanna Aronniemi
- 1 Department of Radiology, University of Helsinki, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Eeva Castrén
- 2 Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - Kimmo Lappalainen
- 1 Department of Radiology, University of Helsinki, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Pia Vuola
- 3 Department of Plastic Surgery, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - Päivi Salminen
- 4 Department of Pediatric Surgery, University of Helsinki, Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Anne Pitkäranta
- 2 Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - Johanna Pekkola
- 1 Department of Radiology, University of Helsinki, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
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Park MH, Kim CM, Chung DY, Paeng JY. Glossectomy in the severe maxillofacial vascular malformation with jaw deformity: a rare case report. Maxillofac Plast Reconstr Surg 2015; 37:42. [PMID: 26609517 PMCID: PMC4646916 DOI: 10.1186/s40902-015-0043-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/10/2015] [Indexed: 11/20/2022] Open
Abstract
In the field of oral-maxillofacial surgery, vascular malformations present in various forms. Abnormalities in the size of the tongue by vascular malformations can cause mandibular prognathism and skeletal deformity. The risk in surgical treatment for patients with vascular malformation is high, due to bleeding from vascular lesions. We report a rare case of macroglossia that was treated by partial glossectomy, resulting in an improvement in the swallowing and mastication functions in the patient. A 25-year-old male patient with severe open-bite and mandibular prognathism presented to our department for the management of macroglossia. The patient had a difficulty in food intake because of the large tongue. Orthognathic surgery was not indicated because the patient had severe jaw bone destruction and alveolar bone resorption. Therefore, the patient underwent partial glossectomy under general anesthesia. There was severe hemorrhaging during the surgery, but the bleeding was controlled by local procedures.
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Affiliation(s)
- Min-Hyeog Park
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Republic of Korea
| | - Chul-Man Kim
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Republic of Korea
| | - Dong-Young Chung
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Republic of Korea
| | - Jun-Young Paeng
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Republic of Korea.,Department of Oral and Maxillofacial Surgery, Kyungpook National University Hospital, 2175 Dalgubeoldae-ro, Daegu, 700-705 Korea
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