Vascular Malformations:

A Rare Case of Internal Jugular Venous Malformation Treated by Surgical Excision

This paper reports a case of an internal jugular venous malformation (IJVM) and route of treatment in a patient with limited symptoms. After history and imaging studies, a determination of surgical excision was made to rule out possible malignancy and future problems such as thrombosis. The mass was resected, and part of the IJVM was ligated. The mass had no identifiable malignancy, and the patient recovered fully with no complications. The paper highlights the importance of identifying venous malformations and highlights the reasoning behind the course of action.

Surgical Management of Vascular Malformations of the Upper Extremity: A 12-Year Retrospective Cohort Study

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.

Recent advances in nanomaterial-driven strategies for diagnosis and therapy of vascular anomalies

Nanotechnology has demonstrated immense potential in various fields, especially in biomedical field. Among these domains, the development of nanotechnology for diagnosing and treating vascular anomalies has garnered significant attention. Vascular anomalies refer to structural and functional anomalies within the vascular system, which can result in conditions such as vascular malformations and tumors. These anomalies can significantly impact the quality of life of patients and pose significant health concerns. Nanoscale contrast agents have been developed for targeted imaging of blood vessels, enabling more precise identification and characterization of vascular anomalies. These contrast agents can be designed to bind specifically to abnormal blood vessels, providing healthcare professionals with a clearer view of the affected areas. More importantly, nanotechnology also offers promising solutions for targeted therapeutic interventions. Nanoparticles can be engineered to deliver drugs directly to the site of vascular anomalies, maximizing therapeutic effects while minimizing side effects on healthy tissues. Meanwhile, by incorporating functional components into nanoparticles, such as photosensitizers, nanotechnology enables innovative treatment modalities such as photothermal therapy and photodynamic therapy. This review focuses on the applications and potential of nanotechnology in the imaging and therapy of vascular anomalies, as well as discusses the present challenges and future directions.

Super Selective Embolization and Immediate Resection of a High-flow Arteriovenous Malformation in the Hand

A significant proportion of high-flow arteriovenous malformations (AVMs) in the hand are complex to treat due to their multicentricity, size, and risk of jeopardizing distal circulation. Therefore, AVMs are frequently considered "inoperable." We present the case of a multifocal recurrent AVM treated in conjunction with the interventional radiology department, with intra-arterial embolization and excision followed by immediate distal revascularization to replace the resulting arterial deficit. This is a case of a 24-year-old woman with a high-flow multifocal AVM in her right hand, partially excised 2 years ago, showing a pulsatile mass in the palm and dorsum of the right hand, and a reporting pain of 8 of 10 on the visual analogue scale. The procedure was performed in our hybrid operating room. This procedure lasted 4 hours, with intraoperative bleeding of 75 mL. Three weeks after the procedure, patency and good circulation of the three revascularized fingers was demonstrated using arteriography and no evidence of vascular anomalies were found. No skin loss occurred, and no reintervention was required. For radical excision of this complex high-flow recurrent AVM, detailed intraoperative documentation of its afferent and immediate embolization with gelatin-based hemostatic agents allowed its obliteration with a low reactive material. We consider that this approach might be an option to treat AVMs that are currently considered inoperable.

Management of a Gluteal Noninvoluting Hemangioma With Glue Embolization and Excision

Noninvoluting congenital hemangiomas (NICHs) persist in a high-flow state into childhood and often require surgical excision. The inherent vascular nature of these tumors make effective surgical treatment challenging. Here we report on a patient that underwent intraoperative glue embolization and complete excision of a large gluteal NICH. Concurrent glue embolization followed by complete excision allows for decreased intraoperative blood loss and easier discrimination between the tumor and surrounding structures. Treating difficult vascular tumors with a multidisciplinary approach and subsequent intraoperative glue embolization with surgical excision allows for an effective, single-stage approach to NICHs.

Die Marginalvene – nach wie vor eine seltene Entität: Fallserie von 16 Patienten

Hintergrund

Die Marginalvene (MV) ist eine angeborene, vorwiegend venöse Gefäßmalformation, die auf einer fehlenden Rückbildung des embryonalen Venensystems an den unteren Extremitäten beruht. Sie geht mit einer Vielzahl an Komplikationen einher. Bisher werden in der Literatur keine einheitlichen Therapieregime beschrieben.

Fragestellung

Welche Behandlungsstrategien und Ergebnisse gibt es bei Patienten mit MV?

Material und Methoden

Im Zeitraum 01.01.2008 bis 31.12.2020 wurden alle am Universitätsklinikum Augsburg behandelten Patienten mit Marginalvene retrospektiv aufgearbeitet.

Ergebnisse

Das mediane Alter zum Diagnosezeitpunkt lag bei 14,8 Jahren (3–42 Jahre). 12/16 Patienten hatten eine Beinlängendifferenz. 75 % der Patienten (12/16) hatten bereits zur Diagnosestellung MV eine chronisch-venöse Insuffizienz (CVI). Im untersuchten Kollektiv wurden 62,5 % (10/16) der Patienten zum Zeitpunkt der Diagnosestellung mittels Kompression konservativ behandelt. Bei weiteren 31,3 % (5/16) der Patienten erfolgte primär eine offen-chirurgische Entfernung der MV und bei 1/16 Patienten wurde die MV primär mittels endovenöser Lasertherapie (EVLT) verschlossen; 15/16 Patienten wurden sekundär therapiert. 2,6 ± 2,4 (MW ± SD) Sekundärprozeduren wurden pro Patient im Follow up durchgeführt. Das mittlere Follow-up lag bei 8,1 Jahren.

Diskussion

Zur Prävention/Vermeidung einer Progression einer CVI und Thrombembolieprophylaxe sollte nach Diagnosestellung die MV zeitnah verschlossen/entfernt werden. Die Anwendung chirurgisch-konventioneller Techniken zur Entfernung der MV scheint gegenüber der Behandlung mit minimal-invasiven Prozeduren hinsichtlich der Anzahl der erforderlichen Sekundäreingriffe von Vorteil.

Neonatal vascular malformation of parietal bone

Vascular malformations (VaMs) are congenital lesions and are present at birth. They grow commensurately with age. These lesions often affect the soft tissues with intraosseous involvement of the scalp being rare. Here, we discuss a case of intraosseous VaM in a 2-month-old infant which was involving the parietal bone.

Characteristics and Academic Productivity Among Pediatric Plastic Surgeons in the United States

BACKGROUND

The characteristics that predispose plastic surgeons to a career in pediatric plastic surgery remain unclear. Therefore, the aim of this study is to analyze the characteristics of current pediatric plastic surgeons and to determine their academic productivity.

METHODS

Pediatric plastic surgeons were identified through an internet search of all academic children's hospitals affiliated with an Accreditation Council for Graduate Medical Education-accredited integrated or independent plastic surgery program. Demographics, training background, institutional and leadership positions, and academic productivity were determined.

RESULTS

A total of 304 pediatric plastic surgeons were identified. The majority of pediatric plastic surgeons were white (n = 217, 71.8%) males (n = 235, 77.6%). Clinical fellowships were completed by 86.8% (n = 263) of the cohort, with craniofacial (n = 181, 59.7%) being the most common followed by hand (n = 54, 17.8%); 41.1% had clinical fellowship training at 10 institutions, with the top 3 most represented programs being University of Pennsylvania (n = 19, 6.2%), University of California-Los Angeles (n = 16, 5.3%), and Harvard University (n = 15, 4.9%); 25.7% (n = 78) held leadership positions within their institutions. A significant higher academic productivity was found among research fellowship-trained surgeons, chiefs of pediatric plastic surgery, fellowship directors, and members of departments of plastic surgery. Those who completed an independent residency had a significant higher H-index and number of citations.

CONCLUSION

Pediatric plastic surgery is represented by surgeons of diverse training background. An elite cohort of programs has trained the most pediatric plastic surgeons. Lastly, high academic productivity was found to be correlated with certain demographic and leadership variables highlighting its impact on career advancement.

Combination Laser Treatment With Real-Time Ultrasound Navigation for Oral Venous Malformations

Vascular lesions, including hemangiomas and vascular malformations, are common benign diseases. More than 50% originate from blood vessels or vascular structures and are locate in the head and neck region. This study aimed to evaluate the efficiency and safety of a combination of laser treatments for oral venous malformations using ultrasound navigation. This study reports 3 cases of massive vascular malformation in the oral cavity, which were treated by a combination of a multiple spotted transmucosal irradiation technique (the so-called leopard technique) for the superficial layer, and intralesional photocoagulation for the deep layer using a neodymium-doped yttrium aluminum garnet laser, under real-time ultrasound navigation. All cases presented with a venous malformation with multiple blue swellings on the dorsum of the tongue, which had a maximum dimension of over 30 mm. The percent reduction in the size of the lesions was determined by magnetic resonance imaging. All cases showed a decrease in lesion volume of over 80%, without extensive tissue necrosis, 6 to 12 months after the laser treatment. None of the patients experienced any complications, and all were satisfied with the treatment outcome after one irradiation session.The results of this study suggest that laser treatment using ultrasound navigation is a promising approach for the safe and minimally invasive resolution of oral vascular lesions without scarring and loss of normal tissue architecture, sensation, oral function.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

BMP9 attenuates occurrence of venous malformation by maintaining endothelial quiescence and strengthening vessel walls via SMAD1/5/ID1/α-SMA pathway

Venous malformation (VM) is a type of vascular morphogenic defect in humans with an incidence of 1%. Although gene mutation is considered as the most common cause of VM, the pathogenesis of those without gene mutation remains to be elucidated. Here, we aimed to explore the relation of bone morphogenetic protein 9 (BMP9) and development of VM. At first, we found serum and tissue BMP9 expression in VM patients was significantly lower than that in healthy subjects, detected via enzyme-linked immunosorbent assay. Next, with wound healing assay, transwell assay and tube formation assay, we discovered BMP9 could inhibit migration and enhance tube formation activity of human umbilical vein endothelial cells (HUVECs) via receptor activin receptor-like kinase 1 (ALK1). Besides, BMP9 improved the expression of structural proteins alpha-smooth muscle actin (α-SMA) and Desmin in human umbilical vein smooth muscle cells (HUVSMCs) via activation of the SMAD1/5-ID1 pathway, determined by RNA-based next-generation sequencing, qPCR, immunofluorescence and western blotting. Intriguingly, this effect could be blocked by receptor ALK1 inhibitor, SMAD1/5 inhibitor and siRNAs targeting ID1, verifying the BMP9/ALK1/SMAD1/5/ID1/α-SMA pathway. Meanwhile, knocking out BMP9 in C57BL/6 mice embryo led to α-SMA scarcity in walls of lung and mesenteric vessels, as well as walls of small trachea. BMP9-/- zebrafish also exhibited abnormal vascular maturity, indicating a critical role of BMP9 in vascular maturity and remodeling. Finally, a VM mice model revealed that BMP9 might have therapeutic effect in VM progression. Our study discovered that BMP9 might inhibit the occurrence of VM by strengthening the vessel wall and maintaining endothelium quiescence. These findings provide promising evidences of new therapeutic targets that might be used for the management of VM.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence‐based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence‐based guidelines for the management of vascular anomalies.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Orthopaedic diagnoses in patients with Klippel-Trenaunay syndrome

PURPOSE

Klippel-Trenaunay syndrome (KTS) is a rare combined vascular malformation composed of capillary malformation, lymphatic and/or venous malformation and limb overgrowth, which commonly affects the extremities. Due to limb involvement, it is not uncommon for these patients to require referral to an orthopaedic surgeon. Herein we reviewed the prevalence of orthopaedic diagnoses in a large cohort of KTS patients and described the associated surgical interventions.

METHODS

Between 1976 and 2012, 410 patients fulfilling strict criteria for KTS were evaluated at a single institution. Patient charts were reviewed for demographic information, details of the clinical evaluation, orthopaedic consultation and surgical interventions.

RESULTS

A total of 264 of 410 patients (64%) with confirmed KTS required orthopaedic evaluation. Of these 264 patients, 84% had documented limb-length discrepancy. Other common diagnoses included: angular deformities (10%), scoliosis (9%), osteopenia/osteoporosis (7%), pathological fractures (6%), joint contracture (5%), degenerative joint disease (4%) and limb/joint pain (4%). Of the 264 patients evaluated by orthopaedic surgery, 133 patients (50.4%) underwent 169 surgeries. Surgery was most commonly performed for limb-length discrepancy (62%). Multivariable analysis confirmed an orthopaedic condition was more likely in patients with lymphatic malformation (odds ratio (OR) 3.78; p < 0.001), as well as in those with bone and/or soft-tissue hypertrophy of the lower extremity (OR 7.51; p < 0.001) or foot (OR 3.23; p < 0.001).

CONCLUSION

Orthopaedic conditions are common in patients with KTS and approximately 50% require surgical intervention. Those with a lymphatic malformation and/or soft-tissue hypertrophy of the lower extremity are more likely to need surgery.

LEVEL OF EVIDENCE

Level IV, Descriptive Case Series.

Ischiorectal fossa: benign and malignant neoplasms of this "ignored" radiological anatomical space

PURPOSE

To review the pertinent anatomy and the imaging features of common and uncommon benign and malignant neoplasms and masses of the ischiorectal fossa.

RESULTS

The ischiorectal or ischioanal fossa is the largest space in the anorectal region. The benign neoplasms that develop in the ischiorectal originate from the different components that forms the fossa including vascular tumors such as aggressive angiomyxoma or hemangioma; neural tumors as plexiform neurofibroma or schwannoma; fat tumors as lipoma; skin/skin appendages tumors as hidradenoma papilliferum; smooth or skeletal muscle tumors as solitary fibrous tumor. The malignant neoplasms that develop in the ischiorectal fossa also originate from different components that forms the fossa including vascular tumors such as angiosarcoma, neural tumors as malignant granular cell tumor and malignant peripheral nerve sheath tumor; fat tumors as liposarcoma; smooth or skeletal muscle tumors as leiomyosarcoma, rhabdomyosarcoma, malignant PEComa, or undifferentiated pleomorphic sarcoma. Additionally, the ischiorectal fossa can also harbor secondary hematogenous metastases and be affected by direct invasion from neoplasms of adjacent pelvic organs and structures. Furthermore, other miscellaneous masses can occur in the ischiorectal fossa including congenital and developmental lesions, and inflammatory and infectious processes.

CONCLUSION

Knowledge of the anatomy, and the spectrum of imaging findings of common and uncommon benign and malignant neoplasms of the ischiorectal fossa is crucial for the radiologists during interpretation of images allowing them to make contributions to the diagnosis and better patient management.

Surgical Resection of Vascular Lesions Involving the Buccal Fat Pad

Vascular abnormalities are localized structural irregularities, which are performed during vasculogenesis, angiogenesis, and lymphangiogenesis. The involvement of soft tissue in such vascular malformations is frequent; however, the compromising of the buccal fat pads (Bichat bags) is uncommon, even in specialized centers, such as the plastic clinic of our institution, in which very few patients have been reported in the literature. The purpose of this article is to present a series of 2 patients in which vascular malformations involving the buccal fat pads, which were extracted by intraoral approach.

Spontaneously Resolved Macrocystic Lymphatic Malformations: Predictive Variables and Outcomes

INTRODUCTION

Lymphatic malformations are benign, low-flow vascular malformations that typically present at or near birth. Due to morbidity associated with operative treatment, nonoperative treatment with injection of sclerosant has become the mainstay of therapy. Over the past 15 years, several patients at our centre with macrocystic (>2 cm cyst size) lymphatic malformations have seen their lesions resolve spontaneously while awaiting treatment. In this study, we review features of these patients that may contribute to spontaneous resolution.

METHOD

A retrospective chart review was conducted from our Vascular Anomalies Clinic database (1999-2014) of all macrocystic lymphatic malformations; characteristics of patients with spontaneous resolution were reviewed.

RESULTS

Of 61 patients with macrocystic lymphatic malformations, 7 cases (11.5%; 4 females, 3 males) resolved spontaneously. Median age at malformation appearance was 2 years (range: 0-6.5 years), with median age at resolution of 4 years (range: 10 months-7 years). Median time from appearance to resolution was 24 months (range: 3-43 months), with a median follow-up time of 4 years (range: 1-15 years). All but 1 case was associated with local or upper respiratory tract infection antecedent to resolution. Six of the 7 lesions were located in the neck.

CONCLUSION

Among the cases reviewed, there was a common theme of upper respiratory tract or local infection antecedent to spontaneous lesion resolution. Compared to the literature, our proportion of malformations presenting after birth and the proportion of malformations presenting in the neck region were higher than those of other series. Although side effects associated with treatment are generally mild and/or rare, risks related to sclerotherapy and the accompanying requirement for general anesthesia in pediatric populations nevertheless exist. As the median time from lesion appearance to resolution was 24 months, it may be reasonable to observe these malformations for up to 24 months before proceeding with treatment if the lesion does not impair function and disfigurement is not considerable, particularly if the lesion presents after birth and/or is located in the neck region.

Improvement of ischemic or congested wound conditions by reconstruction with microsurgical flaps

BACKGROUND

Intractable chronic wounds share the basic problem of the environment being unfavorable for wound healing and prone to infection, inflammation, and recurrences. Microsurgical flap provides a healthy, well-vascularized normal tissue to compromised intractable environment, and promotes wound healing. In this report, we present the results of microsurgical flaps used for the reconstruction of chronic intractable conditions including chronic ulcer with an ischemic environment and pathologic lesions with a congestive environment.

PATIENTS AND METHODS

From 1997 to 2015, 18 patients received microsurgical flaps for chronic intractable conditions. Among them, three patients had radiation ulcers with an ischemic environment and 15 had pathologic lesions with a congested environment, such as vascular malformations. Nine patients were male, and nine were female. The mean age was 31.9 years. All patients were treated using radical excision and reconstruction with microsurgical tissue transfer.

RESULTS

All flaps survived completely. Among three patients with radiation ulcers, two had minor wound disruptions, which were managed conservatively. No further episodes of infections or breakdowns occurred. Among 15 patients who had pathologic lesions, one suffered facial palsy of the forehead. No complications in terms of infection, or recurrences were noted, and resolution of the residual surrounding lesions was observed on follow-ups. No donor related problems occurred in any patients. The mean follow-up period was 10.7 years.

CONCLUSION

In this report, we present the results of reconstruction of chronic intractable conditions using microsurgical flaps. The reconstruction using microsurgical flaps was clinically successful, with long-term improvement of surrounding tissues and no recurrence.

Outcome of Management of Vascular Malformations of Lip

OBJECTIVES

To describe the characteristics and outcome of management of vascular malformations of lip.

PLACE AND DURATION OF STUDY

The Department of Plastic Surgery and Burn Unit, King Edward Medical University, Mayo Hospital, Lahore, from January 2009 to December 2013.

METHODS

A prospective case series of 38 patients with vascular malformation of lip was performed. Demographic information and clinical features were noted. Treatment employed, complications, functional, and cosmetic outcome were recorded. Surgical debulking was performed as definitive treatment in all patients and nonsurgical techniques were added as adjuvant modalities in 18 patients. Sclerotherapy was performed for venous malformations in 10 patients. LASER was performed in 8 patients with capillary or combined malformations. Arterial malformations were managed surgically without embolization. Postexcision defects were closed primarily in 36 patients with Abbe flap in 1 and nasolabial flap in another patient for reconstruction.

RESULTS

Of 38 patients included in the study 20 (53%) were males with mean (SD) age 18 (6) years. Twenty-one percent were high and 79% low-flow malformations (29% venous, 16% capillary, and 34% combined). Lower lip was involved in 70% patients with 95% having difficulty in eating and 87% abnormal speech. Referring diagnosis was incorrect in 35% patients. Postsclerotherapy and postexcision pain scores were mean (SD) 5 (1.26) and 4 (1) respectively. All patients had improvement in eating and speech with restoration of normal muscle function in mean (SD) 5.63 (1.2) weeks. Ninety-five percent patients were satisfied with their outlook. One patient had recurrence at 1 year follow-up.

CONCLUSION

Surgical debulking with proper use of adjuvant procedure for vascular malformations of lip produces best functional and aesthetic results with minimal complications.

Outcomes of Surgical Treatment of Vascular Anomalies on the Vermilion

Background

The vermilion plays an important role in both the aesthetic and functional aspects of facial anatomy. Due to its structural features, the complete excision of vascular anomalies on the vermilion is challenging, making it difficult to determine the appropriate treatment strategy. Thus, the authors analyzed the results of surgical treatment of vascular anomalies on the vermilion.

Methods

The medical records of 38 patients with vascular anomalies on the vermilion who underwent surgery from 1995 to 2013 were analyzed. Nine of the cases had an involuted hemangioma, and 29 cases had a vascular malformation; of the vascular malformations, 13, 11, one, and four cases involved were capillary malformations (CMs), venous malformations (VMs), lymphatic malformations (LMs), and arteriovenous malformations (AVMs), respectively. We investigated the surgical methods used to treat these patients, the quantity of surgical procedures, complications and instances of recurrence, and self-assessed satisfaction scores.

Results

A total of 50 operations were carried out: 28 horizontal partial excisions, eight vertical partial excisions, and 14 operations using other surgical methods. All cases of AVM underwent complete excision. Six cases experienced minor complications and one case of recurrence was observed. The overall average satisfaction score was 4.1 out of 5, while the satisfaction scores associated with each lesion type were 4.2 for hemangiomas, 3.9 for CMs, 4.2 for VMs, 5.0 for LMs, and 4.0 for AVMs.

Conclusions

It is difficult to completely excise vascular anomalies that involve the vermilion. This study suggests that partial excision focused on correcting the overall contour of the lips is effective and leads to satisfactory results.

The "Little AVM": A New Entity in High-flow versus Low-flow Vascular Malformations

BACKGROUND

Arteriovenous malformations (AVMs) are high-flow lesions with abnormal connections between arteries and veins without an intervening capillary bed. Infrequently, the radiographic diagnosis of a vascular lesion will not support the clinical diagnosis of an AVM. These "discrepant" lesions are not adequately captured within the current classification system and represent a treatment dilemma. The purpose of this study is to review our center's experience with vascular malformations where incongruity in a patient's clinical and radiographic presentation produces a diagnostic and therapeutic challenge.

METHODS

A retrospective chart review of patients with atypical AVM pre sen ta tions was performed. Parameters reviewed included patient history and demogra phics, clinical presentation, radiological imaging, and treatment modalities.

RESULTS

Over a 15-year period, we identified 7 cases of vascular malformations with discrepant clinical and radiological findings concerning flow characteristics. All patients were treated based on their radiological diagnosis and most were managed with sclerotherapy. No lesions evolved into a high-flow process, and there was no recurrence at a minimum of 24 months of follow-up.

CONCLUSIONS

We have identified and described a unique subcategory of vascular malformations that have clinical features of high-flow malformations but radiological features of low-flow malformations. These lesions behave like low-flow malformations and should be treated as such. We propose that complex vascular malformations are best evaluated by both clinical and specialized diagnostic radiological means; the radiologic diagnoses should supplant what is found clinically, and ultimately treatment should be preferentially based on a radiological diagnosis.

Management of vascular malformations

BACKGROUND

Even though vascular malformations are well categorized, further details are relatively unknown. Of treated patients regarding the frequency, demographic distributions, and other related factors by multivariate regression analyses in proportion to total vascular malformations, methods of treatment and how to manage them have not been elucidated thoroughly.

METHODS

From January 2006 to March 2012, consecutively treated patients with vascular anomalies were included in this investigation at least 1-year follow-up.

RESULTS

Of the total of 123 cases, 86 females and 37 males, the mean follow-up was 3.5 ± 1.68 years, and the frequency of treatment was 1-8 times (1.8 ± 1.30). Surgery was performed for 22 cases (17.9%) of venous malformations and arteriovenous malformations. In multivariate regression, the frequency of treatment was significantly correlated with the length of follow-up (P < 0.001), age (P < 0.05), and type of malformations (P < 0.05) (R (2) = 0.18). Need for surgery was significantly increased with age at odds ratio (OR) of 1.06 [95% confidence interval (CI), 1.03-1.80] (P < 0.001), and head/face/neck, and upper limb are more performed at OR of 0.24 (95% CI, 0.07-0.85) (P < 0.05). The satisfaction score varied from 1 to 5 (3.9 ± 0.68). Complications occurred in 3 cases (2.4%). In logistic regression of complications, the OR of the satisfaction score was 0.13 (95% CI, 0.02-0.80) (P < 0.05).

CONCLUSIONS

Treatment of vascular malformations is an integral part of multidisciplinary approaches. Venous malformations are more frequent in combination surgery, and if there are fewer complications, the patients' satisfaction increases.

Beta-blockers for the treatment of problematic hemangiomas

OBJECTIVE

To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas.

METHODS

A retrospective review of patients with hemangiomas presenting to the Alberta Children's Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy.

RESULTS

Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%).

CONCLUSIONS

Treatment of infantile hemangiomas with oral beta-blocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment.

The epidemiological profile of the Vascular Birthmark Clinic at the Alberta Children's Hospital

BACKGROUND

The Vascular Birthmark (VBM) Clinic at the Alberta Children's Hospital (Calgary, Alberta) is a multidisciplinary clinic dedicated to the evaluation of children with vascular anomalies.

OBJECTIVE

To review the characteristics of patients seen at the VBM Clinic.

METHOD

A retrospective data analysis of all pediatric patients presenting to the VBM Clinic between 1998 and 2009 was performed. Data including demographic, referring, diagnostic and treatment information were obtained from the clinic's database.

RESULTS

Of 932 patients, 621 with hemangiomas and 311 patients with vascular malformations were found in the database. Hemangiomas were more commonly found in girls (68.5%), and most commonly located on the head and neck (54%), with most patients (72.6%) having only one lesion. Of the patients with hemangiomas, 14.7% underwent diagnostic imaging investigation and 23.7% received treatment including medications, surgery, pulsed-dye laser or dressings. The sex distribution among the 311 patients with vascular malformations was almost equal. Venous malformations accounted for 38.9% of patients, isolated capillary malformations for 31.5%, lymphatic malformations for 11.6%, mixed low-flow malformations for 14.8% and arteriovenous malformations for 2.9%. Overall, 37.9% of patients underwent diagnostic imaging investigation and 42.4% received treatment - either pulsed-dye laser, surgical excision, sclerotherapy or other treatment.

CONCLUSIONS

Hemangiomas and vascular malformations can occur at any anatomical site. There is a large variation in clinical presentation necessitating expertise in a variety of diagnostic approaches and treatment modalities. Vascular anomalies are best managed in a multidisciplinary setting.

The role of serum basic fibroblast growth factor, estradiol and urine basic fibroblast growth factor in differentiating infantile haemangiomas from vascular malformations

OBJECTIVE

To investigate the role of serum basic fibroblast growth factor (bFGF), estradiol (E2) and urine bFGF in differentiating infantile haemangiomas from vascular malformations.

METHOD

Between October 2007 and January 2009, 97 patients with haemangiomas and 25 patients with vascular malformations who had not been treated previously were included in this prospective study. Forty-eight patients with cleft lip and/or palate were selected as controls. The age of all subjects ranged from 1 to 30 months. The serum and urine levels of bFGF were determined by enzyme-linked immunosorbent assay (ELISA). The serum levels of E2 were examined via radioimmunoassay. All data were analysed with SPSS 11.5 software package.

RESULTS

The concentration of serum and urine bFGF was significantly different among the three groups (haemangiomas, vascular malformations and controls) (P = 0.027, P = 0.001). Significantly different urine bFGF levels were found in patients with proliferating and involuting haemangiomas (P = 0.04). The serum E2 levels were significantly higher in patients with haemangiomas than vascular malformations (P = 0.001) and controls (P = 0.001).

CONCLUSION

Serum bFGF and E2 as well as urine bFGF can be used to supplement the clinical diagnosis of congenital vascular anomalies. Urine bFGF combined with serum E2 may be the most potential markers for diagnosing haemangiomas and determining the proliferating stage of haemangiomas.

[Vascular anomalies: information documents]

Vascular anomalies are a complex pathological group. They are composed of hemangiomas and other vascular tumors and congenital vascular malformations: venous, lymphatic, arteriovenous and capillary malformations. The management of these anomalies is difficult and must involve an interdisciplinary approach. To help patients to understand their pathology, we have made some information documents.

Endovenous therapy for the treatment of congenital venous malformations

The treatment of a congenital venous malformation using endovenous radiofrequency ablation in a patient is described. The patient initially underwent two treatments of foam sclerotherapy with moderate success. Later the main feeding vessel of the venous malformation became evident on examination with venous duplex and was identified as the great saphenous vein. At this point, endovenous radiofrequency ablation was used to ablate the feeding vessel and successfully treat the lesion. The procedure proceeded without complications, and the patient made a good recovery. It is recommended that patients presenting with such malformations be considered for endovenous therapy as early as possible.

Composite tissue allotransplantation for the reconstruction of congenital craniofacial defects

Facial disfigurement in children with congenital craniofacial defects can lead to decreased self-esteem and poor self-perception. Traditional methods of reconstruction can fail to achieve a normal appearance in patients with severe disfigurements. Composite tissue allotransplantation (CTA) in children could offer a unique reconstructive opportunity. A discussion of the usage of CTA for congenital craniofacial defects is thus warranted. Treatment of severe craniofacial clefts, Treacher-Collins syndrome, hemifacial microsomia, and some vascular anomalies can yield unsatisfactory results, even after multiple surgeries. CTA provides the advantage of intact vascularized bone that would not need to be reshaped to fit the defect, with the correct donor match. CTA also provides reconstruction with similar tissue type in regions of the central midface such as the nose, lips, and eyelids. With advances in transplant immunology to devise mechanisms to decrease immunosuppression and induce donor antigen-specific tolerance, CTA may be a future reality in the pediatric population.

Management of knee arthropathy in patients with vascular malformations

OBJECTIVE

To describe our experience with surgical intervention for symptomatic intraarticular vascular malformations of the knee in patients with peripheral vascular malformations including Klippel-Trénaunay syndrome (KTS).

METHODS

Eleven patients underwent surgical intervention for symptomatic intraarticular vascular malformations of the knee between 1987 and 2008. Seven patients had KTS, and 4 patients had venous malformations. Surgical indications, imaging studies, clinical course, surgical procedures, complications, and follow-up visits were reviewed and recorded.

RESULTS

A total of 11 patients (8 males; 3 females; mean age, 11.7 years; range, 2.5-23 years) underwent 12 surgical procedures. Five patients had an amputation, and 6 patients had knee synovectomies. One patient had bilateral knee synovectomies. Surgical indications included pain, swelling, limited mobility, and/or loss of knee motion. The average time of follow-up was 54 months (range, 7-109 months). Patient-reported pain scores decreased significantly from a mean of 2.9 +/- 1.4 preoperatively to 1.3 +/- 0.9 postoperatively (P = 0.01).

CONCLUSIONS

When necessary, surgical intervention for intraarticular vascular malformations of the knee (amputation or synovectomy) may be effective in decreasing pain and improving mobility in patients with peripheral vascular malformations. It is possible that early synovectomy may slow or prevent the rapid destructive arthritis that occurs in these knees. Surgeons and patients should anticipate complications related to bleeding from vascular malformations. We recommend a multidisciplinary approach to the patient with KTS, particularly when surgical intervention is indicated.