Congenital Abdominal Aortic Aneurysm: A Case Report and Literature Review

Congenital abdominal aortic aneurysm is a rare disease with unknown etiology, and the common symptoms are abdominal pulsatile mass and pain caused by aneurysm rupture. The disease has a high mortality rate and fewer reports of surgical treatment. Here, we present a case of an idiopathic congenital abdominal aortic aneurysm. A 4-year-old boy had an abdominal pulsatile mass, and computed tomography angiography revealed an isolated infrarenal abdominal aortic aneurysm. To prevent rupture of the aneurysm, we repaired the aneurysm with artificial graft transplantation. No genetic mutation of the known congenital aneurysmal diseases was found in the whole-exome sequencing of the patient and his parents. There was no graft obstruction, and the patient grew well 40 months after surgery. Open surgery is the best treatment for idiopathic congenital abdominal aortic aneurysms. Surgical details such as timing and graft selection need to be further explored.

An integrated multidisciplinary team approach to the management of vascular anomalies: challenges and benefits

BACKGROUND

Vascular anomalies comprise highly variable pathophysiology and commonly pose diagnostic and management dilemmas. Consequently, patients often benefit from input from multiple specialists. This study describes the inception of a multidisciplinary team (MDT) Vascular Anomaly Clinic (VAC) in a tertiary paediatric centre, and the subsequent experience managing this complex patient group.

METHODS

This was a retrospective study of paediatric patients (< 18 years old) attending an MDT VAC from its inception in October 2012 until November 2019. Patient demographics, presentation, diagnosis and management were reviewed.

RESULTS

One hundred and thirty-three paediatric patients were seen over 7 years with a median age of 9.8 years. Vascular malformations were the most common diagnosis (88%), with venous malformations predominating (27%). The most common symptoms were pain (46%) and swelling (34%). Patients often required ≥ 2 investigations, with Doppler ultrasound (86%) and magnetic-resonance imaging (61%) being most common. Management included surgery (27%), sclerotherapy (26%), compression garments (23%), analgesia (12%), laser (15%), embolisation (5%) and sirolimus (3%).

CONCLUSIONS

The complex nature of vascular anomalies and high proportion of patients requiring multi-specialty management justified the establishment of an MDT VAC in our centre. Our experience demonstrates the success of an efficient one-stop MDT environment in the management of these challenging conditions.

LEVEL OF EVIDENCE

IV.

Surgical Treatment of Intra-articular Knee Venous Malformations: When and How?

BACKGROUND

To assess the efficacy of surgical treatment of intra-articular knee venous malformations (VM).

METHODS

Between 1998 and 2010, 8 children (mean age: 12.3 y) underwent surgical resection of their vascular malformation (7 venous and 1 capillary venous) involving the knee joint. The lesion was diffuse in 6 cases and well-demarcated in 2 cases. All children were suffering from knee pain and had recurrent hemarthroses. Color-Doppler ultrasonography, magnetic resonance imaging, computed tomography scan, and blood test were performed preoperatively. Preoperative and postoperative physical examination, clinical symptoms, and orthopaedic evaluation were retrospectively reviewed. Surgery consisted in arthrotomy with total excision of the vascular malformation for the 2 well-demarcated lesions and synovectomy with squeezing of the surrounding vascular malformation for 5 diffuse lesions. One patient with an extensive venous malformation associated with severe localized intravascular coagulopathy and mild hemophilia A had undergone synovectomy by knee arthroscopy.

RESULTS

Immediate postoperative follow-up was uneventful in 6 patients, whereas 2 patients with diffuse vascular malformation and coagulopathy suffered from postoperative hemarthroses, delaying their rehabilitation. After a mean follow-up of 5.1 years, persistence of the VM within the joint was observed in the 6 initially diffuse lesions. The 2 well-demarcated lesions showed no evidence of disease at latest follow-up. Four patients with preoperative chondropathy and functional impairment were not substantially improved regarding their range of knee motion at latest follow-up, whereas the 4 others were free of symptoms. Only 1 patient presented a recurrent hemarthroses after a 5-year-symptom-free period and had to be reoperated. Patients without preoperative chondropathy recovered normal knee function mobility.

CONCLUSIONS

This retrospective study highlights the importance of early surgery in patients with intra-articular venous malformation, even if asymptomatic, to prevent joint impairment. For well-demarcated lesions, total resection by arthrotomy can provide definitive healing without resuming of symptoms. Although diffuse lesions treated by synovectomy still persist in the joint, treatment avoids recurrence of hemarthroses and, therefore, protects the cartilage from further erosion.

LEVEL OF EVIDENCE

Level IV-cases series.

Venous malformation and haemangioma: differential diagnosis, diagnosis, natural history and consequences

Venous malformation (VM) is the most common form of congenital vascular malformation (CVM). VM presents at birth as an inborn vascular defect and never disappears/regresses spontaneously through the rest of life; it will continue to grow slowly at a rate that is proportional to the growth rate of the body. Haemangioma is not a vascular malformation but one of the vascular tumours originating from the endothelial cells; it develops after birth mostly in the infantile/neonatal period with a distinctive growth cycle: a proliferation phase of early rapid growth followed by an involutional phase of slow regression. Although the vascular malformation and vascular tumour belong to the ‘vascular anomaly’ together, both conditions are fundamentally different not only in their anatomical, histological and pathophysiological findings but also in their clinical courses. Therefore, an appropriate differential diagnosis of the VM is mandated not only from other kinds of CVMs but also from ‘genuine’ haemangioma. Appropriate diagnosis and assessment of VMs can be made based on clinical presentation and a proper combination of basic non-invasive studies in general but the presence of a mixed lesion involving other types of CVM lesions and the type of VM lesion, extratruncular and truncular, will dictate the need for further work-up with additional non- to less-invasive study or angiography. Otherwise, angiography is usually reserved for therapeutic planning and treatment.

Sclerotherapy in venous malformation

Venous malformations are the result of an arrested development of the venous system during the embryogenesis. In the treatment of venous malformations the standard of care is a multidisciplinary approach including the use of traditional surgical therapy if applicable and endovascular treatment. Endovascular techniques include embolization therapy for instance with coils but also sclerotherapy with liquid or foamed sclerosants. The aim of this paper is to give an overview of foam sclerotherapy in venous malformations. Sclerotherapy of venous malformations has been performed in superficial and intramuscular malformations. In many cases ethanol has been used for the treatment. Since more than 10 years, less aggressive sclerosants like polidocanol and sodiumtetradecyl sulphate have been used to treat venous malformations. These substances can be used without anaesthesia and the rate of side-effects is much lower. Yamaki and Cabrera are the first who used foam sclerotherapy for the treatment of symptomatic venous malformations. Compared with liquid sclerotherapy foam sclerotherapy has the advantage of a better and longer lasting contact of the sclerosing agent with the vessel wall which leads to a more effective treatment and to a reduction of concentrations needed. In a recent European Guideline on Sclerotherapy foam sclerotherapy is recommended over liquid therapy for the treatment of venous malformations. Foam sclerotherapy is an effective treatment option for low flow extratruncular and truncular venous malformations. Foam is significantly more effective than liquid sclerotherapy and side-effects with polidocanol or sodiumtetradecyl sulphate foam are less compared with sclerotherapy with ethanol. With foam sclerotherapy a significant reduction of pain and volume of the venous malformations can be reached.

Intraosseous Venous Malformations of the Facial Bone: A Retrospective Study in 11 Patients

Objectives:

To investigate the clinical symptoms, computed tomography (CT) features and treatments of intraosseous venous malformations (IVM) that occur in the facial bone.

Methods and Results:

Eleven patients with facial IVM were treated with two surgical techniques, excision ( n = 4) or curettage ( n = 7). No recurrence was encountered at follow-up (45.8 ± 16.0 months). Postoperative deformities were left in two paediatric patients who were treated with excision.

Conclusions:

The diagnosis of IVM can be difficult and is mainly based on clinical symptoms and CT features. IVM should be differentiated from other lesions, including ameloblastoma, odontogenic cysts, osteosarcoma, aneurysmal bone cysts and arteriovenous malformations, among others. Conventional block biopsy should be replaced by fine needle aspiration cytology for further diagnosis. Curettage is a more appropriate method for IVM compared with excessive en-bloc osteotomy, while transosseous embolo-sclerotherapy may be a promising alternative method. Finally, the terminological confusion between ‘intraosseous haemangioma’ and ‘intraosseous venous malformation’ should be avoided according to the binary classification.

Arterio-venous malformation: how much do we know?

Arterio-venous malformation (AVM) is a congenital vascular malformation that is neither a venous malformation nor a haemangioma. An AVM is a potentially life-threatening and limb-threatening lesion, especially the 'fistulous' truncular form due to its unique embryological and haemodynamic characteristics. AVM treatment requires an early aggressive approach, one that is careful and based on a thorough assessment of the risks and benefits associated with the treatment plan. A successful treatment strategy requires an accurate assessment of the AVM taking into account the extent, severity and progression of the lesion. This is critical in order to minimize the morbidity associated with the currently available therapies. A multidisiciplinary approach that integrates endovascular and surgical therapy can substantially improve the treatment results seen in patients with AVMs. Preliminary treatment of a fistulous AVM with coil embolization is essential in order to minimize associated morbidity and to alter the lesion haemodynamics from a high-flow lesion to a low-flow lesion that is more amenable to subsequent, definitive management with ethanol or NBCA glue embolo/sclerotherapy.