An interdisciplinary specialist team leads to improved diagnostics and treatment for paediatric patients with vascular anomalies

Dyadic coping experiences of parents of children with vascular anomalies

BACKGROUND

Vascular anomalies (VAs) are a spectrum of rare pediatric disorders that require coordinated care from multiple subspecialists. Parents often struggle to coordinate care for their child's complex rare disorder. Even when they do access expert care, parents of children with VAs report high levels of stress and uncertainty. While previous research has explored parents' experiences navigating care for VAs, we know very little about how parents cope with stress together. Given the effect that dyadic coping can have on individual, couple, family, and child outcomes, we aimed to gain a better understanding of dyadic coping in the context of VAs.

PROCEDURES

We collected data using semi-structured interviews with 27 parents (13 dyads and one individual parent). Data were analyzed using dyadic thematic analysis.

RESULTS

Parents experienced stress related to medical, personal, logistical, and financial aspects of their child's healthcare. They relied on eight coping strategies: active coping, seeking emotional support, seeking informational support, cognitive avoidance, distraction, cognitive reframing, acceptance, and internalization. When analyzed together, we found evidence of five dyadic coping dynamics: collaborative, supportive, delegated, separate, and negative.

CONCLUSION

Dyadic coping is complex and multilayered for parents of children with VAs. While the child's diagnosis is considered a shared stressor, both parents may not share preferred coping strategies. Parents of the same child may also be coping with different medical, relational/social, personal, or logistical stressors altogether. Psychosocial interventions designed to facilitate parental coping should address these complex coping dynamics.

Factors affecting the ability of patients with complex vascular anomalies to navigate the healthcare system

BACKGROUND

Vascular anomalies (VAs) are rare congenital disorders that can cause pain, disfigurement, coagulopathy, asymmetric growth, and disability. Patients with complex VAs experience multiple barriers to accessing expert care. It is imperative to understand which factors support these patients' ability to navigate the healthcare system.

RESULTS

We surveyed adult patients with VAs using previously validated measures, recruiting participants from five patient advocacy groups and multidisciplinary VA clinics. The primary outcome was self-reported ability to access needed medical care, using the "Navigating the Healthcare System" subscale of the Health Literacy Questionnaire. We evaluated factors associated with the ability to navigate the healthcare system using multivariate linear regression (n = 136). We also performed an exploratory model that included the primary care doctor's knowledge of VAs for the subset of participants with a primary care doctor (n = 114). Participants were predominantly women (n = 90, 66%), White and non-Hispanic (n = 109, 73%), and college-educated (n = 101, 73%). Most participants had PIK3CA-Related Overgrowth Spectrum (n = 107, 78%). Most participants reported that navigating the healthcare system was "sometimes" or "usually difficult" (mean score 16.4/30, standard deviation 5.6). In multivariate linear regression, ability to navigate the healthcare system was associated positively with quality of information exchange (β = 0.38, 95% Confidence Interval (CI) 0.22 to 0.55, p <.001) and whether patients had VA specialists (β = 2.31, 95% CI 0.35 to 4.28, p =.021), but not associated with patient self-advocacy, anxiety, education, age, race and ethnicity, gender, or having a primary care doctor. In exploratory analysis of participants with primary care doctors, ability to navigate the healthcare system was positively associated with quality of information exchange (β = 0.27, 95% CI 0.09 to 0.45, p =.004), having a VA specialist (β = 2.31, 95% CI 0.22 to 4.39, p =.031), and primary care doctors' VA knowledge (β = 0.27, 95% CI 0.04 to 0.50, p =.023).

CONCLUSION

Patients with VAs struggle to navigate the healthcare system. High-quality information from clinicians and more knowledgeable primary care doctors might help patients to access needed care. Relying on patient self-advocacy is insufficient. Future efforts should focus on patient-directed and clinician-directed educational interventions. Additionally, future work should assess the structural barriers that impede healthcare access for these patients.

Patient characteristics and disease spectrum in a German vascular anomalies center

BACKGROUND

Vascular malformations are rare diseases that should be treated in dedicated vascular anomaly centers (VAC). There is only a small amount of data on the diagnostic and therapeutic handling of these patients, before they are referred to a VAC.

PURPOSE

To demonstrate the disease-specific patient characteristics in a German VAC, which are required to determine diagnostic and therapeutic steps.

MATERIAL AND METHODS

In a retrospective study, all patients who were treated in the VAC from April 2014 until August 2021 were identified. In total, 593 patients were included in this study.

RESULTS

Almost all patients had previously consulted a physician (591/593, 99.7%). A mean of two different physicians had been consulted (range 0-10). Patients with more complex, syndromal vascular malformations had significantly more previous appointments (P = 0.0018). In only 44% (261/593) of patients, the referral diagnosis was made correctly. Most patients had been previously treated for their vascular anomaly: pharmacotherapy (n = 130; 21.9%), compression garments (n = 141; 23.8%), surgical resection (n = 80; 17.3%) and sclerotherapy (n = 68; 11.5%). Fifty-two patients who had been falsely diagnosed had also received therapy prior to their referral to the VAC (8.8%). Most patients received an ultrasound examination in the VAC (n = 464; 78.2%). Most frequently, compression therapy was prescribed (n = 256; 43.2%), followed by sclerotherapy (n = 175, 29.5%) and pharmacotherapy (n = 55; 9.3%).

CONCLUSION

Patients suffering from vascular anomalies often go through a complicated scheduling with numerous outpatient appointments and have a high risk of misdiagnosis and mistreatment prolonging the medical condition. Therefore, patients with vascular anomalies should be treated in a dedicated vascular anomaly center.

Vascular Anomalies Care in the United States: A Cross-Sectional National Survey

OBJECTIVE

To characterize the current distribution, composition, and practice patterns of multidisciplinary vascular anomalies (VAs) teams in the US.

STUDY DESIGN

This is a cross-sectional survey of children's hospitals in the US offering VAs care. We approached 142 children's hospitals that provided care for VAs via email. The survey evaluated VA clinic location, medical staffing, research participation, and treatments offered. The survey was administered between October 2021 and July 2022.

RESULTS

Participants from 95 eligible hospitals responded to the survey (response rate = 67%). Large areas of the Midwest and Northwest US had no available multidisciplinary VA teams or clinics. Most respondents worked at academic centers (89%), with 66% at a freestanding children's hospital, and 56% reported having a multidisciplinary clinic. Most common physician participants in clinic included hematology-oncology (91%), interventional radiology (87%), dermatology (85%), plastic surgery (81%), and otolaryngology (74%). Only 38% of programs included medical geneticists. Smaller hospitals had fewer medical and ancillary staff and offered fewer therapeutic options. Research was available at most larger institutions (69%) but less commonly at smaller hospitals (34%).

CONCLUSIONS

Major portions of the US lack multidisciplinary VA care. Furthermore, VA programs vary in composition and geneticists are absent from the majority of programs. These findings should inform efforts to address disparate access and develop standards of care for multidisciplinary VA care in the US.

Sociodemographic characteristics of pediatric patients with vascular malformations: Results of a single site study

Vascular malformations, the abnormal development of blood vessels, are a rare set of congenital anomalies. The sociodemographic factors associated with vascular malformations in pediatric patients are poorly understood. This study examined sociodemographic factors of 352 patients presenting to a single vascular anomaly center from July 2019 to September 2022. Characteristics such as race, ethnicity, sex, age at presentation, degree of urbanization, and insurance status were recorded. This data was analyzed by comparing the different types of vascular malformations, including arteriovenous malformation, capillary malformation, venous malformation (VM), lymphatic malformation (LM), lymphedema, and overgrowth syndrome. Patients were primarily white, not Hispanic or Latino, female, had private health insurance, and were from the most urban setting. No differences in sociodemographic factors were found among the different vascular malformations except patients with VM presented at a later age than patients with LM or overgrowth syndrome. This study provides novel insight into the sociodemographic factors of pediatric patients presenting with vascular malformations and indicates a need for their improved recognition for the timely initiation of treatment.

Long-term outcomes of lymphatic malformations in children: An 11-year experience from a tertiary referral center

BACKGROUND

Lymphatic malformations (LMs) are benign, congenital lesions that display considerable heterogeneity in terms of size, location and characteristics. This study aims to describe the long-term outcomes of current management strategies for patients with simple (cystic) LMs.

METHODS

The case records of all patients (age ≤16 years) with simple (cystic) LMs at our tertiary institution between 2008 and 2019 were assessed for clinical features, imaging and details of management, including complications.

RESULTS

Of a total of 164 patients (60% male), 66% were diagnosed aged <2 years. The median follow-up was 5 (0.3-16) years from diagnosis. LMs were located in the head and neck (40%), extremities (27%), trunk (23%), mediastinum (4%), or intra-abdominally (6%). Types were macrocystic in 47%, microcystic in 21% and mixed in 32%. Sclerotherapy was the most common intervention (38%). Primary surgery had been performed in 12%. Symptomatic improvement, reduction in size, or complete regression were observed in 82/102 (80%) of LMs after interventions; complications from treatment were uncommon (Clavien-Dindo grade I-II: 6%; grade III-IIId: 1%). Sixty-two patients (38%; median age 0.5 (range, 0-12) years) had not required interventions to date; spontaneous regression of the LM occurred in 16 (26%) of these expectantly followed-up cases.

CONCLUSIONS

Most studies to date have focused on LMs in selected anatomical locations. Herein the outcomes of an entire population from a single tertiary unit of patients are presented, demonstrating the wide heterogeneity of simple (cystic) LMs and highlighting the importance of individualized, multidisciplinary approaches to care in achieving optimal outcomes.

Performance of a vascular anomaly center: a retrospective analysis of 461 cases over seven years

BACKGROUND

Vascular malformations are rare diseases that are best managed in multidisciplinary vascular anomaly centers (VAC). So far, there are few published data on the logistic structure, patient allotment, and internal workflow in an interdisciplinary VAC.

PURPOSE

To demonstrate the referral structure and patient allotment in a European VAC.

MATERIAL AND METHODS

A retrospective cohort study was conducted. All patients treated in the VAC since its establishment in April 2014 until June 2020 were identified. A total of 461 patients were included in this study.

RESULTS

Most often, a venous malformation was diagnosed (49.9%), followed by arteriovenous malformations (8.7%) and syndromal vascular malformations (8.2%). Only 45.1% of referral diagnoses were correct. Of referrals, 35.1% were internal on-campus references, 28.0% were external references through physicians in private practice, and 19.7% came via external cooperating hospitals. Of the patients, 17.1% were self-admissions without a referral.

CONCLUSION

The most important referring clinics are internal medicine, pediatric, and vascular surgery. A substantial proportion of referrals came from private practices. Recruiting these cooperation partners should be considered a high priority when establishing a new VAC. The rate of misdiagnosis is high, and more education of fellow clinicians is urgently needed. Therefore, patients with vascular malformations should be referred to and treated in dedicated centers for vascular anomalies.

Factors affecting pathways to care for children and adolescents with complex vascular malformations: parental perspectives

Background

Complex vascular malformations (VMs) are rare disorders that can cause pain, coagulopathy, disfigurement, asymmetric growth, and disability. Patients with complex VMs experience misdiagnosis, delayed diagnosis, delayed or inappropriate treatments, and worsened health. Given the potential consequences of delaying expert care, we must identify the factors that impede or facilitate this access to care.

Results

We performed semi-structured interviews with 24 parents (21 mothers; 3 fathers; median age = 42.5 years) of children with complex VMs and overgrowth disorders living in the US, recruited through two patient advocacy groups – CLOVES Syndrome Community, and Klippel-Trenaunay Support Group. We performed thematic analysis to assess parental perspectives on barriers and facilitators to accessing expert care. We identified 11 factors, representing 6 overarching themes, affecting families’ ability to access and maintain effective care for their child: individual characteristics (clinician behaviors and characteristics, parent behaviors and characteristics), health care system (availability of specialist multidisciplinary teams, care coordination and logistics, insurance and financial issues, treatments and services), clinical characteristics (accuracy and timing of diagnosis, features of clinical presentation), social support networks, scientific progress, and luck and privilege. Additionally, access to information about VMs and VM care was a crosscutting theme affecting each of these factors. These factors influenced both the initial access to care and the ongoing maintenance of care for children with VMs.

Conclusion

Parents of children with VMs report multiple factors that facilitate or impede their ability to provide their child with optimal care. These factors represent possible targets for future interventions to improve care delivery for families affected by VMs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02432-4.

Screening for cerebrovascular disorder on the basis of family history in asymptomatic children

Background: Cerebrovascular disorders represent a group of uncommon, heterogeneous, and complex conditions in children. We reviewed the screening practice for the detection of cerebrovascular disorder in asymptomatic children referred to our neurovascular service on the basis of a positive family history and parental and/or treating physician concern.Methods: Retrospective case-note review of referrals to our neurovascular service (July 2008-April 2018). Patients were included if the referral was made for screening, on the basis of a positive family history of cerebrovascular disorder. Symptomatic children, those with previous cranial imaging, or children under the care of a clinical geneticist (i.e. due to the child or their relative having HHT or mutations in KRIT1) were not eligible for inclusion.Results: Forty-one children were reviewed, 22 males (Median age 10.7 years, range 0.6-15.6 years). This represented 22% of the total number of referrals over a 10-year period. Twenty-nine children had an MRI/MRA brain. Twenty-eight children were referred due to a family history of intracranial aneurysm and/or subarachnoid haemorrhage, but only two had two first-degree relatives affected. Ten children were referred due to a family history of arteriovenous malformation. Three children were referred due to a family history of stroke. No cerebrovascular disease was detected during the study period (n = 29).Conclusions: Parental and/or physician concern generated a substantial number of referrals but no pathology was detected after screening. Whilst general screening guidance exists for the detection of intracranial aneurysms, consensus guidelines for the screening of children with a positive family history do not, but are required both to guide clinical practice and to assuage parental and/or physician concerns.

A Vascular Malformation in the Carotid Sheath at the Carotid Bifurcation Mimicking Carotid Body Tumor

BACKGROUND

The carotid sheath contains clinically important and vital anatomical neurogenic, vascular, and lymphatic structures that allow for a great variety of lesions. Vascular anomalies found in the carotid sheath are rarely reported and may be easily misdiagnosed as arterial aneurysms, neurogenic tumors, paragangliomas, or lymphatic masses.

METHOD

We present a 60-year-old woman with a vascular malformation arising within the carotid sheath at the right carotid bifurcation, which mimics carotid body tumor.

RESULT

The mass was excised successfully with an uneventful postoperative course, and histological analysis suggested a vascular malformation with thin-walled blood vessels, lined by endothelial cells and separated by fibrous tissue. The patient was in good clinical condition without signs of relapse of the mass at 6-month follow-up.

CONCLUSION

Vascular malformation is a rare but existing possibility of pathology in the carotid sheath, which can be effectively removed by meticulous surgery.

Communication and the Appraisal of Uncertainty: Exploring Parents' Communication with Credible Authorities in the Context of Chronic Childhood Illness

Individuals with chronic illnesses must manage long-term uncertainty as they cope with the ways the illness influences their lives. In the context of pediatric illnesses, parents must manage uncertainty during the diagnosis and treatment of their child's illness. It is common for children with complex chronic illnesses to see multiple specialists for the treatment of their condition. While previous research has explored parents' uncertainty during a child's diagnosis and during end-of-life care, less is known about these experiences when the child is referred to a team of specialists for treatment. The aim of the current study was to explore how specialists, as credible authorities, influence parents' uncertainty during parents' first visit to a multidisciplinary clinic for the care of their child's complex chronic illness. Data were collected through semi-structured interviews with 29 parents after their child's first visit to a vascular anomaly clinic at a large Midwestern children's hospital. The results suggest parents' communication with credible authorities facilitates effective uncertainty management primarily through the mechanism of uncertainty reappraisal. The results also suggest that specialists, as credible authorities, are a key mechanism in the appraisal of uncertainty for conditions that are often misdiagnosed and mismanaged.

[Vascular anomalies. Part II: vascular malformations]

Vascular malformations are congenital vascular anomalies with normal endothelial turnover, which can affect the whole vessel tree (arterial, capillary or lymphatic) both as isolated defects or as part of a syndrome. Developmental errors during embryogenesis, such as abnormal signaling processes that control the apoptosis, maturation and growth of vascular cells, lead to the persistence of vascular plexus cells with some degree of differentiation. Vascular malformations are usually present at birth, although symptoms or complications may be manifested later. Since the overwhelming majority are symptomatic, treatment is indicated which is often aimed only at improving the symptoms by controlling the size.

Interdisciplinary Management of Head and Neck Vascular Anomalies: Clinical Presentation, Diagnostic Findings and Minimalinvasive Therapies

OBJECTIVES

Vascular anomalies are included in the 30 000 rare diseases worldwide affecting less than 5/10 000 people. Depending on their morphology and biological properties, they can cause varied disorders with organ involvement. Almost 60% of vascular anomalies have a predilection for the head and neck region in children. Clinical and scientific effort to establish interdisciplinary management concepts for vascular anomalies is increasing worldwide.

METHODS

Especially in the head and neck region, clinical impairment and organ dysfunction is associated with cosmetic issues that may represent a physical and psychological issue for the patient. Correct diagnosis, based on clinical presentation and symptoms, is a prerequisite for appropriate therapy, ranging from conservative management to a spectrum of minimally invasive treatment options. We searched PubMed for German and English language published data until December 2016 with focus on clinical studies, review articles and case reports on vascular anomalies with a focus on the head and neck region.

RESULTS

The last ISSVA update in 2014 has contributed to a better understanding of vascular anomalies, classifying them in vascular tumors and vascular malformations. The predominant representatives of vascular tumors are congenital and infantile hemangiomas. Infantile hemangiomas have the ability of spontaneous regression in more than 80%. Patients with symptomatic growing hemangiomas with ulcerations, bleeding complications and restriction of hearing, swallowing disorder, impairment of vision, or cosmetic dysfigurement require treatment. Therapies include oral propanolol, transcatheter embolization and surgery. Vascular malformations tend to progress with patientś age and are subdivided in slow flow and fast flow lesions. Symptomatic slow flow lesions, e.g. venous and lymphatic malformations, benefit from percutaneous sclerotherapy. Fast flow lesions, as arteriovenous malformations, are rare but undoubtedly therapeutically the most challenging vascular anomaly. Depending on location and size, they may require multiple transcatheter embolization procedures for successful occlusion of the AVM.

CONCLUSIONS

This review provides knowledge on the current ISSVA classification of vascular anomalies, their clinical presentation, diagnostic evaluation and minimally invasive therapy options to encourage the establishment of a comprehensive interdisciplinary management for head and neck vascular anomalies.

Inheritance Patterns of Infantile Hemangioma

BACKGROUND AND OBJECTIVE

Infantile hemangioma (IH) includes, among its other risk factors, familial clustering, but a definitive understanding of IH's inheritance model and genetic basis is lacking. Our objective was to collect IH pedigrees in Finland, to study the inheritance patterns of IH within these families, and to analyze the characteristics of familial IHs.

METHODS

We identified 185 patients with IH who visited our vascular anomaly clinic between 2004 and 2007. Based on hospital records and a questionnaire sent to these patients and their families, IH characteristics and family history of IH were studied. We compared characteristics between patients with positive (familial) and negative (sporadic) IH family history. Families with positive IH family history were further interviewed for extended pedigree data.

RESULTS

One-third of our IH cohort's families reported a family history positive for IH, with IH characteristics and perinatal data between the familial and sporadic cases being similar. IH patients with affected first-degree relatives reported higher long-term discomfort rates than the sporadic cases. Of the 40 families interviewed, 11 included ≥4 IH-affected family members; these were most commonly first-degree relatives (63%). Segregation patterns match with autosomal dominant inheritance with an incomplete penetrance or maternal transmission. We also present a case of monozygotic twins that manifest identical IHs.

CONCLUSIONS

Based on this large number of IH pedigrees, we suggest at least 2 possible mechanisms of inheritance: autosomal dominant and maternal transmission. This study highlights the need for additional genetic studies to define inheritance of this common disease.

Low dose time-resolved CT-angiography in pediatric patients with venous malformations using 3rd generation dual-source CT: Initial experience

OBJECTIVES

To prospectively evaluate the diagnostic value and radiation dose of time-resolved CT-Angiography (4D-CTA) in pediatric patients with venous malformations using 3rd generation dual-source CT (DSCT) at 70 kVp tube voltage.

METHODS

Between November 2014 and August 2015, seven children (2 male, 5 female; median age, 9 years; range 3-12 years) with suspected peripheral, non-cerebral, venous malformations were included in this feasibility study and underwent US, MRI and 4D-CTA. All three imaging modalities were analyzed and compared individually by an experienced interventional radiologist and a pediatric surgeon using a 5-point Likert scale, with regard to diagnosis of the vascular anomaly, additional information like presence of thrombophlebitis and lesion extension, flow dynamics, localization, volume and significance for treatment planning. For quantitative statistical analysis, an unifactorial analysis of variance was performed for every parameter and all three imaging modalities. Radiation dose values as expressed by the volume CT dose index (CTDIvol) and dose-length product (DLP) were recorded for of all patients.

RESULTS

Three out of six patients had isolated type I venous malformations without peripheral venous drainage which could be demonstrated on MRI and CT. In two out of six patients a type II venous malformation with drainage into normal veins was diagnosed. In one case, 4D-CT was the only imaging modality that revealed a slow-flow venous malformation with shunting supply by a hypodynamic arterial feeder.

TREATMENT PLANNING

4D-CTA was rated as the best imaging modality for treatment planning with agreement between radiologist and surgeon, especially with respect to the hemodynamics of the venous malformation.

CONCLUSIONS

4D-CTA at 70 kVp is a fast imaging modality that provides comprehensive diagnostic information of venous malformations in pediatric patients and is very valuable for therapy planning. Radiation dose of 4D-CTA must be weighted against the diagnostic information as well as the potential risk for sedation and contrast administration during MRI.

Risk factors and morbidity of infantile haemangioma: preterm birth promotes ulceration

AIM

We identified the characteristics of an infantile haemangioma (IH) that predispose children to complications, interventions and long-term morbidity and examined perinatal risk factors for IH.

METHODS

We studied children with IHs admitted to Helsinki University Hospital's paediatric vascular anomaly clinic in Finland in 2004-2007 and registered perinatal records, IH characteristics, complications and interventions. These patients received a questionnaire on perinatal data and long-term morbidity resulting from IH. We analysed factors related to complications, interventions and morbidity and compared our cohort's perinatal data to the Finnish Medical Birth Register (FMBR) figures.

RESULTS

We approached 185 families, of which 136 replied to the questionnaire. Children with facial, segmental and indeterminate IHs showed more complications, interventions and higher long-term morbidity. Preterm birth predisposed infants to ulceration of IHs, with a 95% confidence interval (CI) of 1.02-5.14 and odds ratio (OR) of 2.29. In addition to earlier known risks, maternal gestational diabetes mellitus rate was higher in our IH cohort than the rate in the FMBR (95% CI 1.39-4.95, OR 2.62).

CONCLUSION

Physicians treating IHs should consider the elevated ulceration risk in preterm infants. The association between gestational diabetes mellitus and child's risk for an IH is uncertain and requires further research.

Pediatric lymphatic malformations: evolving understanding and therapeutic options

Multimodal treatment of lymphatic malformations continues to expand as new information about the biology and genetics of these lesions is discovered, along with knowledge gained from clinical practice. A patient-centered approach, ideally provided by a multidisciplinary medical and surgical team, should guide timing and modality of treatment. Current treatment options include observation, surgery, sclerotherapy, radiofrequency ablation, and laser therapy. New medical and surgical therapies are emerging, and include sildenafil, propranolol, sirolimus, and vascularized lymph node transfer. The primary focus of management is to support and optimize these patients' quality of life. Researchers continue to study lymphatic malformations with the goal of increasing therapeutic options and developing effective clinical pathways for these complicated lesions.

Update on the Use of Ultrasound in Vascular Anomalies

Advances in our understanding of the biology and therapy of vascular anomalies have made this condition a common reason for consulting a dermatologist. In addition, multidisciplinary units have been created to manage patients with complex vascular anomalies. Although most vascular anomalies are diagnosed based on clinical findings, a thorough evaluation often requires additional imaging tests to determine the nature, extension, and prognosis of these lesions. Because it is fast and noninvasive, ultrasound is usually the first imaging test ordered. In the present review, we provide a state-of-the-art synthesis of key concepts in the ultrasound examination of vascular anomalies so that they are more accessible to clinicians and medical imaging specialists involved in the management of these lesions.