Effectiveness and Safety of Ethanol for the Treatment of Venous Malformations: A Meta-Analysis

New Insights into Cervicofacial Vascular Anomalies

Congenital cervicofacial vascular anomalies are extremely rare and present many difficulties in diagnosis and treatment requiring a multidisciplinary approach. Firstly, there is little consensus on this subject among head and neck specialists. There are two main types of vascular anomalies: vascular tumors and vascular malformations. Vascular malformations are also divided into malformations with slow blood flow (veins, lymphatics, capillaries or combined) and malformations with a fast blood flow (arteriovenous malformations and fistula). Vascular tumors like hemangiomas are known for their spontaneous involution with aging, while vascular malformations grow in dimensions with age. It is very important to choose the correct differential diagnosis between cervicofacial hemangiomas and vascular malformations for proper therapy management. Anamnesis and clinical exams help in raising suspicions about the real nature of a cervico-vascular anomaly. Furthermore, imaging brings in-depth details of the anomaly, ranging from ultrasound and contrast CT to MRI scanning and minimally invasive angiography. Angiography with selective embolization is rarely a curative procedure for arteriovenous malformations, being more suitable as a preliminary step before attempted surgical removal. Surgery is clearly necessary when there are aesthetic and functional deficits. Slow-flow vascular malformations present a reduced morbidity, and in cases without involution, the surgical ablation is reserved for the cases with aesthetic dysfunctions or psychological trauma. Lymphatic malformations must undergo surgical ablation when they are associated with mass effects and compression of great vessels or aerial viscera. The prognosis after surgical removal is good, with a low rate of recurrence or morbidity. Fast-flow vascular malformations require a combined approach, with embolization and excision in the next 48 h for safety reasons. Removal may be followed by reconstructive surgery depending on the location and dimensions of the malformation, with a possible secondary recovery of the normal microscopic vessels. Some of the masses may hinder the normal airflow and swallowing. Pathology is the gold standard for confirming the clinical and imaging diagnosis.

A systematic review and network meta-analysis of the effectiveness of sclerotherapy for venous malformation

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.

Value of Dynamic Contrast-Enhanced (DCE) MRI in Predicting Response to Foam Sclerotherapy of Venous Malformations

BACKGROUND

Preoperative imaging assessment of venous malformations (VMs) and prediction of foam sclerotherapy efficacy might be achievable by DCE-MRI but elaborate quantitive analysis was absent.

PURPOSE

To evaluate the value of DCE-MRI in predicting the effectiveness of foam sclerotherapy in VMs.

STUDY TYPE

Retrospective.

POPULATION

Fifty-five patients (M:F = 17:38; mean age ± SD, 15.4 ± 13.0 years) with VMs.

FIELD STRENGTH/SEQUENCE

Three Tesla MRI with 3D T₁ -weighted volume interpolated body examination.

ASSESSMENT

Patients who underwent pretreatment DCE-MRI were divided into "effective" and "ineffective" groups according to the response to foam sclerotherapy. Clinical characteristics and morphologic features were assessed. The semiquantitative parameters, such as maximum intensity time ratio (MITR), enhancement ratio (ER), and Slope, were obtained from ROI and volume of interest (VOI). The quartile and mean values of these parameters were acquired from VOI, while mean values denoted as Mean^# were acquired from ROI. Establishment of two predictive models was based on ROI and VOI respectively. Model 1 was based on morphologic parameters and ROI semiquantitative parameters, while model 2 was based on morphologic parameters and VOI semiquantitative parameters.

STATISTICAL ANALYSIS

Mann-Whitney U-test, Cohen's kappa, multivariate logistic regression analysis (backward stepwise), and ROC analyses.

RESULTS

The lesion classification, presence of phlebolith, semiquantitative parameters of VOI (quartile and mean of MITR), and semiquantitative parameters of ROI (Slope_mean ^# , MITR_mean ^# ) were significantly different between two groups. Lesion classification (P = 0.002) and MITR_mean# (P = 0.027) were independent predictors for poor efficacy in model 1 as determined by multivariate binary logistic regression analysis. For model 2, lesion classification (P = 0.006) and MITR₂₅ (P = 0.001) were independent predictors. The predictive model based on VOI (AUC = 0.961) performed better than that based on ROI (AUC = 0.909) in predicting therapeutic response.

DATA CONCLUSION

DCE-MRI is promising in predicting the response to foam sclerotherapy for VMs. The whole lesion VOI-based model showed better performance and could instruct surgical approach in the future.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 4.