Klippel-Trenaunay syndrome with small vessel pulmonary arterial hypertension

Pulmonary Manifestations of Skin Disorders in Children

Systemic diseases often manifest with cutaneous findings. Many pediatric conditions with prominent skin findings also have significant pulmonary manifestations. These conditions include both inherited multisystem genetic disorders such as yellow-nail syndrome, neurofibromatosis type 1, tuberous sclerosis complex, hereditary hemorrhagic telangiectasia, Klippel-Trénaunay-Weber syndrome, cutis laxa, Ehlers-Danlos syndrome, dyskeratosis congenita, reactive processes such as mastocytosis, and aquagenic wrinkling of the palms. This overview discusses the pulmonary manifestations of skin disorders.

Pulmonary thromboembolic events in patients with congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and spinal/skeletal abnormalities and Klippel-Trénaunay syndrome

OBJECTIVE

Patients with Klippel-Trénaunay syndrome (KTS) and congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and spinal/skeletal abnormalities (CLOVES) syndrome have central phlebectasia and enlarged persistent embryonic veins that are often incompetent and prone to thromboembolism. The purpose of the study was to determine the presence of phlebectasia and the incidence of symptomatic pulmonary embolism (PE).

METHODS

A retrospective review was conducted of patients referred to the Vascular Anomalies Center at our institution during a 21-year period who were diagnosed with KTS and CLOVES syndrome. Of these, the patients who had PE were screened for thromboembolic risk factors in addition to phlebectasia and the presence of persistent embryonic veins. Treatment outcomes following subsequent endovascular and medical therapies were reported.

RESULTS

A total of 12 KTS patients of 96 (12.5%) and 10 CLOVES syndrome patients of 110 (9%) suffered PE. Fourteen patients (64%) developed PE after surgery or sclerotherapy. All of the patients had abnormally dilated central or persistent embryonic veins; 20 patients were treated with anticoagulation (1 died at the time of presentation, and no information was available for 1) after PE, and 14 (66%) patients underwent subsequent endovascular treatment. Five patients developed recurrent PE despite anticoagulation. Two of the patients died of PE. No patients treated with endovascular closure of dilated veins had subsequent evidence of PE.

CONCLUSIONS

Patients with KTS and CLOVES syndrome are at high risk for PE, particularly in the postoperative period.

Characterization of thrombosis in patients with Proteus syndrome

Patients with overgrowth and complex vascular malformation syndromes, including Proteus syndrome have an increased risk of thromboembolism. Proteus syndrome is a mosaic, progressive overgrowth disorder involving vasculature, skin, and skeleton, and caused by a somatic activating mutation in AKT1. We conducted a comprehensive review of the medical histories and hematologic evaluations of 57 patients with Proteus syndrome to identify potential risk factors for thrombosis. We found that six of ten patients, who were deceased, died secondary to deep venous thrombosis and/or pulmonary embolism. Of the remaining 47 living patients, six had thromboembolic events that all occurred postoperatively and in an affected limb. Eleven of 21 patients had an abnormal hypercoagulable panel including Factor V Leiden heterozygotes, antithrombin III deficiency, positive lupus anticoagulant, or Protein C or S deficiencies. We observed that eight of 17 patients had an abnormal D-dimer level >0.5 mcg/dl, but deep venous thromboses occurred in only four of those with D-dimer >1.0 mcg/dl. We conclude that the predisposition to thrombosis is likely to be multifaceted with risk factors including vascular malformations, immobility, surgery, additional prothrombotic factors, and possible pathophysiologic effects of the somatic AKT1 mutation on platelet function or the vascular endothelium. The D-dimer test is useful as a screen for thromboembolism, although the screening threshold may need to be adjusted for patients with this disorder. We propose developing a registry to collect D-dimer and outcome data to facilitate adjustment of the D-dimer threshold for Proteus syndrome and related disorders, including PIK3CA-Related Overgrowth Spectrum.

Pulmonary emboli associated with isolated lower-extremity venous malformation: a case report

Pulmonary thromboembolism is a relatively rare entity in the pediatric population; however, it should always be part of the differential diagnosis in patients with the appropriate clinical presentation. We report the case of a 13-year-old girl with a history of a lower-extremity venous malformation status post sclerotherapy 2 years prior but otherwise healthy who presented with painless hemoptysis. She was found to have multiple bilateral pulmonary emboli on computed tomographic angiography of the chest. Magnetic resonance venography of the lower extremities showed stable venous changes from prior studies and no obvious source of emboli. She was started on anticoagulation and was discharged home.

Diagnosis and management of extensive vascular malformations of the lower limb: part II. Systemic repercussions [corrected], diagnosis, and treatment

At least nine types of vascular malformations with specific clinical and radiologic characteristics must be distinguished in the lower limbs: Klippel-Trénaunay syndrome, port-wine stain with or without hypertrophy, cutis marmorata telangiectatica congenita, macrocephaly-capillary malformation, Parkes Weber syndrome, Stewart-Bluefarb syndrome, venous malformation, glomuvenous malformation, and lymphatic malformation. Extensive vascular malformations are often more complex than they appear and require a multidisciplinary therapeutic approach. Vascular malformations may be associated with underlying disease or systemic anomalies. Part II of this two-part series on the diagnosis and management of extensive vascular malformations of the lower limb highlights the systemic repercussions [corrected] (bone, articular, visceral, and hematologic involvement), diagnosis, and treatment of these lesions.

Venous thrombosis and pulmonary embolus in pediatric patients with large upper extremity venous malformations

Patients with large venous malformations are at risk for deep venous thrombosis and pulmonary embolus. Currently, there is no general consensus on the proper treatment for these patients. We present 3 preadolescent patients with large upper extremity venous malformations, who developed deep venous thrombosis; 2 had documented pulmonary emboli, one of which was fatal. It is imperative that patients and families be educated regarding the potential life-threatening sequelae that may be associated with these large vascular malformations.

Klippel-Trenaunay-Weber syndrome: orodental manifestations and management considerations

Klippel-Trenaunay-Weber syndrome is characterized by a triad of features, namely, vascular nevi, venous varicosities, and hyperplasia of hard and soft tissues in the affected area. Involvement of the orofacial region is uncommon, but nevertheless, a wide range of orofacial abnormalities may necessitate specialized dental and anesthesia management. We have documented the manifestations in 2 affected persons, outlined the nosology, reviewed the literature, and tabulated craniofacial anomalies and orodental complications. Special emphasis is given to the hematologic factors (bleeding tendencies) and vascular involvement (hemangiomata) which may significantly influence orodental management and anesthesia.