The Other Side of Chronic Venous Disorder: Gaining Insights from Patients' Questions and Perspectives

Venous disorders encompass a diverse range of manifestations and diseases, impacting a significant portion of the population. While life-threatening conditions are uncommon in non-thrombotic disorders, like telangiectasias or uncomplicated varicose veins (VVs), these conditions still have a substantial impact on affected individuals. Ensuring that patients are well informed about their venous disorder is a crucial step in their treatment journey. Providing them with valuable information regarding the disease's natural progression and available therapeutic options plays a pivotal role in optimizing their care. When patients are diagnosed with venous disorders, they often have numerous questions and concerns they want to discuss with their healthcare providers. Addressing these inquiries not only improves patients' knowledge and understanding but also influences their treatment compliance and overall outcomes. Therefore, it is of utmost importance to provide comprehensive explanations that address any doubts, uncertainties, and areas of confusion that patients may have. This report aims to present a concise, practical, and informative guide to venous disorders, focusing specifically on the common questions frequently raised by patients in everyday clinical practice. By serving as a valuable resource for healthcare professionals working in the field of venous diseases, this guide equips them with the necessary tools to effectively address patients' concerns and provide optimal care. By bridging the gap between patients' inquiries and medical expertise, this guide strives to enhance therapeutic outcomes and improve the overall management of venous disorders, ultimately empowering patients in their treatment journey.

Hypothalamic-pituitary dysfunction in Sturge-Weber syndrome: case report and review of the literature

OBJECTIVES

Sturge-Weber syndrome (SWS) is a rare neurocutaneous disorder that is characterized by a segmental dermatomal facial port-wine stain birthmark and is frequently accompanied by ipsilateral brain and eye abnormalities. We present a case of a patient with SWS who exhibited hypogonadotropic hypogonadism, growth hormone (GH) deficiency, and central hypothyroidism at the age of 20 despite the absence of radiographic findings in the pituitary and hypothalamus.

CASE PRESENTATION

A 20-year-old male with SWS with epilepsy and Klippel-Trenaunay syndrome presents with delayed pubertal development, short stature, and obesity. Upon further examination, he was found to have biochemical and clinical evidence of hypogonadism, hypothyroidism, and GH deficiency. A pituitary MRI displayed no abnormalities of the pituitary or hypothalamus. Treatment with testosterone cypionate and levothyroxine was initiated. Despite successful pubertal induction, IGF-1 levels have remained low and treatment with recombinant human growth hormone (rhGH) is now being considered for metabolic benefits.

CONCLUSIONS

This case emphasizes the importance of endocrine evaluation and treatment of hormonal deficiencies in patients with SWS despite the absence of radiographic findings.

Klippel–Trenaunay Syndrome: Employment of a New Endovascular Treatment Technique—Mechanochemical Ablation Using the Flebogrif System

Background: Klippel–Trenaunay syndrome (KTS) is characterized by a triad of symptoms; varicose veins and venous malformations (VMs), capillary malformations (port-wine stain), and soft tissue and bone hypertrophy. Herein, we retrospectively studied six patients with KTS who underwent treatment with the Flebogrif system and evaluated their outcomes. Methods: Six KTS patients aged 16–22 years who had undergone 18 non-thermal ablations using the Flebogrif system were enrolled. All patients underwent multistage foam sclerotherapy with 3% polidocanol at 3–4-week intervals. Results: Venous clinical severity score (VCSS) analysis showed improvement in the patients’ clinical condition. All patients reported a significant improvement in aesthetic outcomes. One patient presented with recanalization of ablated marginal veins during the 24-month follow-up period. Patients could return to full activity within 7–10 days after the procedure. None of the patients experienced serious systemic complications. Conclusion: The use of the Flebogrif system in treating various forms of chronic venous insufficiency, including in patients with KTS, provides a high success rate with a high closure rate.

Klippel-Trenaunay Syndrome: Case series from a university hospital of Nepal

Introduction

Klippel Trenaunay Syndrome (KTS) is a rare congenital malformation with capillary and venous malformations and soft tissue/bony overgrowth with or without lymphatic malformation. Cutaneous vascular stain, varicosities and tissue hypertrophy represent its main clinical features. Besides, the patient can develop thromboembolic pathologies, recurrent bouts of infection, stasis eczema, limb length discrepancy and intolerable pain typical of intraosseous involvement.

Methods

Here, we report a case series of seven patients aged 10–45 who presented to our centre with clinical features suggestive of KTS. Out of them, six patients had involvement of unilateral lower limb, while only one had involvement of bilateral lower limb. They all had typical cutaneous vascular stains and underlying venous malformation, while one patient had developed complications with multiple ulcer formation.

Outcomes

An interdisciplinary team of vascular surgeons, dermatologists, interventional radiologists, orthopaedics, and physiotherapists managed the cases. We performed an individualized treatment as per the patient's presentation, which included a combination of supportive, medical, interventional radiologic, and surgical interventions. The follow-up outcomes of all the patients revealed significant resolution of symptoms.

Conclusion

Patients with KTS can have diverse presentations. Therefore, clinicians should ensure an individualized treatment with the involvement of a multidisciplinary team for proper management and prevention of complications.

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Compilation of eight cases of lower limb Klippel-Trenaunay Syndrome (KTS) successfully managed by a multidisciplinary approach.

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Primary complaints include pain, geographic vascular stain and, prominent dilated veins.

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Demonstration of individualized management algorithm, which yields a good outcome.

A rare case of persistent lateral marginal vein of Servelle in Klippel Trenaunay Syndrome: A successful surgical management

Introduction and importance

Klippel-Trenaunay Syndrome (KTS) is a rare congenital vascular disorder characterized by capillary malformation, varicosities, and tissue overgrowth. It usually affects the unilateral lower extremities manifesting commonly as pain, localized rise of temperature, and venous tortuosity. However, in severe cases, ulceration, cellulitis, and chronic lymphatic malformation may be present. Management is mostly supportive and involves the use of compression stockings.

Case presentation

Here, we report a case of KTS with a persistent lateral marginal vein of Servelle managed with radiofrequency ablation along with sclerotherapy of selected perforators. On a two-year follow-up, the symptoms had resolved and Doppler ultrasonography revealed resolution of the defective vein along with the absence of incompetent perforators.

Clinical discussion

In cases with venous malformation with the persistence of embryonic avalvular venous structures, like the lateral marginal vein of Servelle, surgical intervention is warranted especially at a younger age to reduce the risk of future thromboembolic events and recurrence.

Conclusion

Varicosities of the lateral marginal vein of Servelle can be managed successfully by radiofrequency ablation and adjunct sclerotherapy in selected cases.

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Klippel-Trenaunay Syndrome (KTS) is a congenital vascular disorder which usually affects the unilateral lower extremities.

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Endovenous treatment of the greater saphenous vein is gradually becoming popular in the treatment of KTS.

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This case is managed by radiofrequency ablation of lateral marginal vein of Servelle.

A neonate with Klippel-Trénaunay syndrome: a case report

Background

Klippel–Trénaunay syndrome is a rare congenital capillary–lymphatic–venous condition characterized by the clinical triad of capillary malformations (port wine stains), varicose veins with or without venous malformations, and bony and/or soft-tissue hypertrophy. It has a very low incidence of about 1:100,000.

Case presentation

We report the case of 21-day-old neonate Black African female (born in Uganda) with Klippel–Trénaunay syndrome who presented with macrodactyly and ectrodactyly on the left foot, as well as numerous port wine stains on the left thoracoabdominal region and anteroposterior left lower limb. Color Doppler ultrasound examination of the left lower limb and abdomen revealed varicose veins without signs of arteriovenous fistula.

Conclusion

The report presents the case of a neonate with a rare congenital vascular disorder type Klippel–Trénaunay syndrome.

Klippel-Trenaunay syndrome (KTS): A report of two patients and review of literature

Klippel-Trenaunay syndrome (KTS) is an uncommon congenital condition, resulting in vascular malformations affecting capillary, venous, and lymphatic systems and bone and/or soft tissue hypertrophy. Magnetic Resonance Angiography (MRA) may be useful in assessing the severity of the disease and for treatment planning. We present two cases of two white men with the typical clinical presentation of Klippel-Trenaunay syndrome i.e. vascular malformations (capillary, venous and lymphatic) and localized bone and/or soft tissues hypertrophy. Splenic hemangiomas were evidenced in both patients and MRA was helpful in assessing and delineating the abnormal venous drainage system. KTS is a complex disorder whose true prevalence and etiology are still unknown. In most cases the emblematic clinical manifestation consisting in vascular malformations and extremity overgrowth is represented. KTS may be associated with several different conditions including scoliosis and splenic hemangiomas. The presence of the lateral marginal vein (LMV) is pathognomonic. Imaging is fundamental in confirming the diagnosis and for therapeutic strategies. An effective treatment does not exist to date and a multidisciplinary approach is usually required to prevent complications.

Usefulness of triggered non-contrast-enhanced magnetic resonance angiography in assessing lower extremity venous disease

Although venous duplex ultrasonography (USG) is reliable for diagnosing lower extremity venous disease (LEVD), cross-sectional imaging studies were usually required before intervention or surgery. Patients of LEVD with renal insufficiency usually restrict the use of contrast-enhanced imaging modalities. In seeking an alternative imaging solution for these patients, we explore the clinical utility of triggered angiography non-contrast-enhanced magnetic resonance imaging (TRANCE-MRI) in the assessment of LEVD.We collected data from patients presenting to a tertiary wound-care center with symptoms of LEVD from April 2017-November 2019. Each participant underwent baseline USG followed by TRANCE-MRI on a 1.5T MR scanner (Philips Ingenia, Philips Healthcare, Best, The Netherlands). Inter-rater reliability was measured using Cohen's kappa (κ).All 80 participants (mean age, 61.9 ± 14.8 years; 35 males, 45 females) were assessed and were classified into one of five disease groups, deep vein thrombosis (n = 38), venous static ulcer (n = 16), symptomatic varicose veins (n = 18), recurrent varicose veins (n = 3), and lymphoedema (n = 5). The inter-rater reliability between TRANCE-MRI and doppler USG showed substantial agreement (κ, 0.73). The sensitivity, specificity, and accuracy of TRANCE-MRI were 90.5%, 88.1%, and 88.8%, respectively. In 59 (73.8%) USG-negative patients, we were able to diagnose positive findings (deep venous thrombosis, n = 7; varicose veins, n = 15; lymphedema, n = 10; iliac vein compression with thrombosis, n = 6; external venous compression, n = 5; vena cava anomaly, n = 2; occult peripheral artery disease, n = 5; ccluded bypass graft, n = 1) by using TRANCE-MRI. Of these, 9 (15.3%) patients underwent additional vascular surgery based on positive TRANCE-MRI findings.TRANCE technique provides the limb's entire venous drainage in clear images without background contamination by associated arterial imaging. Additionally, simultaneous evaluation of bilateral lower extremities can help determine the lesion's exact site. Although TRANCE-MRI can provide MR arteriography and MR venography, we recommend performing only MR venography in symptomatic LEVD patients because the incidence of occult arterial disease is low.

Coagulation issues in vascular anomalies

Vascular anomalies, comprised of vascular tumors and malformations, are frequently associated with coagulopathy. Recognition of and familiarity with these vascular anomaly-associated hematologic abnormalities prior to surgery or interventional procedures is essential for pre-operative pre-operative planning. Complicated coagulopathies present within the framework of either Kasabach-Merritt phenomenon (KMP) or localized intravascular coagulopathy (LIC), and their management benefits from the expertise of a hematologist for optimal intra- and peri‑operative care. Furthermore, with the recent broadening of understanding of vascular anomalies and the addition of new classification sub-groups, distinctions of these two classic coagulopathy phenotypes have been recognized. This review summarizes the main features of these coagulopathies, described according to their vascular anomaly type, highlighting clinical aspects relevant to surgical management.

Retrospective study of hematologic complications in patients with slow-flow vascular malformations undergoing sclerotherapy

BACKGROUND

Slow-flow vascular malformations (SFVM) are associated with localized intravascular coagulopathy (LIC), which is characterized by elevated D-dimer and, when severe, hypofibrinogenemia. LIC results in intralesional clotting and hemorrhage and increases risk for significant thrombotic and bleeding complications. Sclerotherapy has been a suggested potential trigger for LIC worsening to disseminated intravascular coagulopathy. Hematologic complications of sclerotherapy in SFVM, along with low-molecular-weight heparin (LMWH) used to prevent worsening LIC, are largely unstudied.

PROCEDURE

Medical records of patients with SFVM and LIC who underwent sclerotherapy at Cincinnati Children's Hospital Medical Center from July 2008 to December 2016 were reviewed for periprocedural hematologic complications. LMWH dose, frequency, and course length were evaluated.

RESULTS

Fifty-nine patients with SFVM and LIC underwent 281 sclerotherapy procedures, of which 86% were in children. Eighty-five percent of patients received periprocedural LMWH, although at various doses and course lengths. No thrombotic complications occurred in children. One adult on LMWH developed pulmonary emboli after sclerotherapy. No major bleeding complications occurred postoperatively. In four patients, fibrinogen dropped below 100 mg/dL post-sclerotherapy, requiring cryoprecipitate. One patient required packed red blood cell (RBC) transfusion for sclerotherapy-induced hemolysis. No intraoperative bleeding or thrombotic events occurred.

CONCLUSION

LMWH use, at subtherapeutic dosing, was common in this patient population and did not appear to increase risk of significant bleeding before, during, or after sclerotherapy. In children with SFVM, bleeding and thrombotic complications after sclerotherapy appear rare. Although safe, prospective studies are needed to evaluate the efficacy of LMWH to prevent worsening coagulopathy with procedures.

Eine außergewöhnliche Therapie der Vena-iliaca-externa-Hypoplasie bei einer Patientin mit Klippel-Trénaunay-Syndrom – ein Fallbericht

Das Klippel-Trénaunay-Syndrom (KTS) ist eine seltene und komplexe Fehlbildung. Sie zeigt die typische Trias aus vaskulärer Malformation, Knochen- und Weichteilhypertrophie sowie venöser Varikosis. Die Systemmanifestationen werden in einem individuell variablen Muster beobachtet. Eine isolierte angeborene Hypoplasie des venösen Systems tritt jedoch in den seltensten Fällen auf. Aus diesem Grund spielt die Früherkennung eine wichtige Rolle für die weitere Behandlungsplanung. So können durch rechtzeitige Behandlung schwere Krankheitsverläufe oder Spätfolgen vermieden werden. Eine isolierte angeborene Hypoplasie ist extrem selten und prädisponiert insbesondere im jungen Erwachsenenalter für Becken- oder Beinvenenthrombosen. Bei dieser Krankheit wird selten eine chirurgische Rekonstruktion durchgeführt.

Wir beschreiben einen sehr seltenen Fall einer 60-jährigen Frau mit KTS, die vor 28 Jahren einen venösen Crossover-Bypass (Palma) mittels Vena saphena magna bei Hypoplasie der Vena iliaca externa rechts erhalten hat. Das Ziel des vorliegenden Berichts ist das klinische Erscheinungsbild, den diagnostischen Prozess und das Krankheitsmanagement vorzustellen sowie eine Literaturübersicht zum operativen Behandlungsverfahren darzustellen.

Periosteal new bone formation in Klippel-Trénaunay syndrome: a case report

BACKGROUND

Klippel-Trénaunay syndrome (KTS) is a complex congenital vascular disorder, typically accompanied by port-wine stains, varicose veins, and limb hypertrophy. This paper reports a rare and unusual clinical condition of periosteal reaction in a pediatric case of KTS. Although periosteal new bone formation is not rare in children, as is KTS, their dual occurrence or the presentation of the former due to KTS has not been previously documented. Our objective in this study is to highlight the potential association between periosteal new bone formation and KTS, as well as to help physicians consider this association when bone neoplasm has been ruled out.

CASE PRESENTATION

A 7-year old girl, initially presented with a persistent mild swelling in her left shank, with no abnormalities in the X-ray of the tibiofibular. However, after a few consults and examinations, 7 weeks later, a 17 cm-long periosteal new bone formation along the left tibia and diffused dilated vessels in the left shank were revealed by the radiological examination. Not knowing the true nature of the fast-growing lesion in a typical case of KTS was worrying. Therefore, a core needle biopsy was performed. The test demonstrated a possible parosteal hemangioma. Following further investigation through an excisional biopsy, and a pathological analysis, hyperplasia of the bone tissues with no tumor cells was revealed. Thereafter, an elastic stocking treatment was prescribed. During the first two-year follow-up, recurrence of the mass or sign of progression of KTS was not observed.

CONCLUSIONS

Periosteal new bone formation is a potential manifestation of KTS. Based on the conclusive pathological results of the excisional biopsy, invasive examinations and surgeries could be avoided in future KTS-subperiosteal lesion manifestations.

Long-Term Management and Maxillofacial Growth in a Klippel-Trenaunay Syndrome Patient

Klippel-Trenaunay syndrome (KTS) is a congenital disorder associated with capillary, venous, lymphatic vascular malformations, and unilateral hypertrophy of the soft tissue and bone. We report a case of a 5-year-old girl with KTS who was followed up until age 17. The asymmetry of her maxillary dentition became remarkable with growth, although no significant left-right difference in either the maxilla or mandible was recognized. Acceptable occlusion was achieved without fixed orthodontic appliances; however, it was necessary to develop treatment plans in accordance with the general symptoms of the disease.

Conservative management of knee arthropathy in a patient with Klippel Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a rare vascular malformation characterized by capillary malformation, venous malformations, and soft tissue or bone hypertrophy that affect the extremities in most cases. Knee or hip arthropathy are common associated conditions and cause serious disability. We present the case of a patient with a diagnosis of KTS and severe knee arthropathy. A 34-year-old man with KTS was referred to our hospital with severe knee arthropathy, with the joint fixed in a 90° position. CT Angiography and MRI of the left leg showed important varicose development of the superficial venous system with intraarticular vessels. After discussion of the case by a multidisciplinary committee, the patient was enrolled on a physiotherapy program and had achieved significant improvements in movement and quality of life at 12-month follow-up. Treatment of KTS is primarily conservative and a multidisciplinary approach is necessary.

Presentation and Management of Klippel-Trenaunay Syndrome: A Review of Available Data

Klippel-Trenaunay Syndrome (KTS) is a rare and sporadic congenital disorder, characterized by the classical triad of port-wine stains, varicosities along with bone and soft tissue hypertrophy. Symptoms of Klippel-Trenaunay Syndrome include pain, swelling, lymphedema, bleeding, superficial thrombophlebitis, and deep vein thrombosis. The etiology remains indistinct and has been attributed to both genetic and environmental factors. In most cases, a thorough history and clinical examination is enough for the diagnosis of Klippel Trenaunay Syndrome. However, when certain complications are present, noninvasive imaging techniques are used for the diagnosis and evaluation of the disease in patients. Due to the diversity of presentation, a multidisciplinary approach is essential for the proper management of such patients. At present, there is no cure for the disease; rather, symptomatic treatment is employed in order to improve the patients' quality of life. In this review, we provide a brief overview of the clinicopathological profile and management of Klippel-Trenaunay Syndrome.

Klippel-Trenaunay syndrome as a rare cause of chronic thromboemboembolic pulmonary hypertension

Klippel-Trenaunay syndrome (KTS) is a congenital disorder characterized by cutaneous capillary malformations, soft tissue and bone hypertrophy, and multiple capillary, venous or lymphatic malformations. KTS is associated with recurrent thromboembolic events. We reported herein five cases of chronic thromboembolic pulmonary hypertension (CTEPH) associated with KTS (age minimum-maximum 26-50 years old, 3 males/2 females). Hemodynamics showed severe pulmonary hypertension (PH) with pulmonary vascular resistance ranging from 5.6 to 18.3 Wood units (WU), associated with marked clinical impairment (NYHA functional class III or IV in 4 patients). Computed tomography (CT) of the chest and pulmonary angiography confirmed proximal CTEPH accessible to surgical intervention in one patient and distal forms of CTEPH in 4 patients. Evolution after pulmonary endarterectomy showed hemodynamic normalization, while the patients with distal CTEPH had severe outcomes with 2 early deaths after PH diagnosis (44 and 35 months respectively). One patient with distal CTEPH was still alive 16 years after diagnosis on specific PH therapy and one was transplanted after 15 years because of right heart failure (death after 12 months). Histological analysis of the lung explants showed typical chronic thromboembolic material specific for CTEPH. In conclusion, KTS may be complicated by severe CTEPH requiring careful anticoagulation and multidisciplinary follow-up in expert centers to screen for disease potentially accessible to endarterectomy. In the modern management era of CTEPH, balloon pulmonary angioplasty will certainly be an interesting option in patients with inoperable disease.

Klippel-Trenaunay Syndrome

Klippel-Trenaunay syndrome or KTS is a complex vascular syndrome associated with overgrowth occurring as a result of somatic mutations in the PIK3CA gene. Patients are diagnosed on the basis of physical findings, sometimes with supportive imaging, of commonly a segmental anomaly with a cutaneous port-wine stain, lymphatic and venous malformations and overgrowth. The severity of the component vascular malformations and the degree of overgrowth varies from patient to patient which demands care given by a multi-professional team with regular follow-up in a specialist clinic. Some patients may present with acute life-threatening problems, often as a result of veno-thromboembolic events (VTEs) especially following surgical and invasive radiological procedures. Awareness of such problems is vital and prophylactic measures to reduce such risks are paramount. The interventional radiologist is vital to the care team as he/she can undertake procedures including endovascular closure of significant venous anomalies which predispose to such VTEs. Although these procedures can be lengthy and complex, they can now provide a minimally invasive means to reduce the risk from life-threatening and sometimes fatal VTEs. The results however from such interventions will require long-term studies which to date are unavailable.

Implementation of new endovenous treatments in therapy for lateral embryonic veins

Klippel-Trénaunay syndrome is characterized by a persistent lateral embryonic vein. This so-called marginal vein has a large diameter causing venous stasis and venous hypertension because of the absence of valves along its entire length. The extensive diameter of the vein impedes successful treatment by sclerotherapy. Surgical removal is considered technically challenging for potential severe intraoperative blood loss due to the large perforators to the deep veins. Here we show that endovenous treatments (laser ablation, cyanoacrylate adhesive) might be feasible options in therapy for lateral embryonic veins.

An atypical case of Klippel-Trénaunay syndrome presenting with crossed-bilateral limb hypertrophy and postaxial polydactyly: a case report

Background

Klippel-Trénaunay syndrome (KTS) is a rare congenital condition characterized by the clinical triad of capillary malformations (port wine stains), varicose veins with or without venous malformations, and bony and/or soft tissue hypertrophy.

Case presentation

Here we report the first case of a one-day-old male with KTS presenting with crossed-bilateral limb hypertrophy and post-axial polydactyly.

Conclusion

This case serves to highlight the variable presentation and multiple problems faced by patients with KTS and why multidisciplinary management is mandatory.

Klippel-Trenaunay-Weber Syndrome with Atypical Presentation of Cerebral Cavernous Angioma: A Case Report and Literature Review

BACKGROUND

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare syndrome characterized by the triad of cutaneous hemangiomas, venous varicosities, and osseous-soft tissue hypertrophy of the affected limb. Clinical manifestations, genetic testing, and radiologic imaging are the key steps in diagnosing this syndrome.

CASE DESCRIPTION

An 18-month-old boy was brought for follow-up brain magnetic resonance imaging (MRI) with a history of right lower limb hypertrophy, cutaneous varicosities, and hemangiomas diagnosed at birth. A baseline MRI at 12 months revealed multiple hemorrhagic lesions within the cerebrum, the largest in the right temporal lobe, which was treated surgically at the age of 18 months because of its rapid growth. This is the youngest patient with KTWS treated surgically for intracranial hemangiomas.

CONCLUSION

KTWS is a rare disease with a wide range of manifestations. Multisystemic evaluation of this group of patients should be performed to identify cavernous hemangiomas at the early stage of life and adequately treat them in the future. Treatment of KTWS patients with cavernous hemangiomas should not be different from the treatment of patients with any other hemangiomas, and surgical intervention should be considered on a case-to-case bases.

Kyphoscoliosis with Klippel-Trenaunay syndrome: a case report and literature review

Background

Klippel-Trenaunay syndrome (KTS) is a rare congenital syndrome characterized by the triad of venous varicosities, capillary malformations and limb hypertrophy. However, KTS may rarely occur in combination with kyphoscoliosis.

Case presentation

We presented an 18-year-old female with KTS and kyphoscoliosis. Hypertrophy of bone and soft tissue affected her left face, trunk and lower limb. Moreover, the patient is associated with subacute thyroiditis, vitamin D deficiency and iron deficiency anemia, high level of D-dimer, swollen tonsil, kyphoscoliosis and Chiari-I-malformation without syringomyelia. A posterior correction and spinal fusion from T10 to L5 levels were performed for this patient. The lumbar curve was corrected from 105° to 60° and the kyphosis improved from 58° to 26°. The distance of trunk shift decreased from 10 cm to 1.4 cm. There were no thrombotic events occurred. At the 8th month follow-up, there was no significantly change of the curve in the coronal and sagittal radiographs. During the 31-month follow-up, the patient did not experience any discomfort. And her general appearance did not have any change until the last follow-up. However, she refused to take radiograph for worrying about radiation.

Conclusions

KTS is a rare disease with classic clinical triad. However, it can also have other different features, including kyphoscoliosis, elevated D-Dimer, vitamin D deficiency and iron-deficiency anemia. These issues should be taken into consideration when planning treatment for kyphoscoliosis in KTS patients.

Superficial Femoral Venous Aneurysm in a Patient with Klippel-Trenaunay Syndrome: The Femoral Hernia Mimic

Venous aneurysms are a rare vascular anomaly characterized by a solitary area of dilatation containing all three layers of the venous vessel wall. Described throughout the venous system, venous aneurysms can be classified as deep or superficial based on the vein involved. Although generally asymptomatic, superficial venous aneurysms can be associated with venous insufficiency or venous thromboembolism and are often confused for soft tissue masses or hernias. In young adults, venous aneurysms are often associated with Klippel-Trenaunay syndrome. In this report, we present a case of a primary superficial venous aneurysm in a patient with Klippel-Trenaunay syndrome mimicking a femoral hernia.

Diagnosis and management of the venous malformations of Klippel-Trénaunay syndrome

OBJECTIVE

A dearth of information exists in the literature regarding current practice in the management of Klippel-Trénaunay syndrome (KTS), a rare condition. We review and describe the etiology, diagnosis, and treatment of KTS.

METHODS

Relevant data were synthesized from a Medline review using a combination of the keyterms "Klippel" and "Trénaunay." The majority of hits described singular case reports and were subsequently excluded. The remaining papers were then reviewed and included on the basis of the quality of evidence and the authors' discretion.

CONCLUSIONS

KTS is characterized by a clinical triad of extremity varicosities, cutaneous vascular malformations, and hypertrophy of soft tissues and long bones. The diagnosis is clinically supplemented with magnetic resonance imaging and computed tomography. Although this syndrome is associated with significant comorbidities, such as pain, edema, ulcerations, and pruritus, it is rarely the cause of death. The backbone of treatment is nonoperative in nature but should be supplemented with minimally invasive, endovascular, and rarely open surgical procedures for refractory cases.

[Quality standards for ultrasonographic assessment of peripheral vascular malformations and vascular tumors. Report of the french society for vascular medicine. 2018 Update]

The quality standards of the French Society of Vascular Medicine for the ultrasonographic assessment of vascular malformations are based on the two following requirements: (1) technical know-how: mastering the use of ultrasound devices and the method of examination; (2) medical know-how: ability to adapt the methods and scope of the examination to its clinical indication and purpose, and to rationally analyze and interpret its results.

AIMS OF THE QUALITY STANDARDS

To describe an optimal method of examination in relation to the clinical question and hypothesis. To homogenize practice, methods, glossary, and reporting. To provide good practice reference points, and promote a quality process.

ITEMS OF THE QUALITY STANDARDS

The 3 levels of examination; their clinical indications and goals. The reference standard examination (level 2), its variants according to clinical needs. The minimal content of the examination report; the letter to the referring physician (synthesis, conclusion and proposal for further investigation and/or therapeutic management). Commented glossary (anatomy, hemodynamics, semiology). Technical bases. Setting and use of ultrasound devices. Here, we discuss ultrasonography methods of using of ultrasonography for the assessment of peripheral vascular malformations and tumors (limbs, face, trunk).

Cutis marmorata telangiectatica congenita and major lower limb asymmetry

A 39-week-old male newborn presented at birth with atrophic erythematous and purpuric skin lesions, in a typical right-sided segmental distribution. Lesions were persistent and unaffected by rewarming in the postpartum period. Postnatal echocardiogram showed a predominance of the right cavities and an upper atrial septal defect. Cerebral and abdominal ultrasound were normal along with ophthalmological examination. On follow-up, lower limbs asymmetry was noted. The right lower limb was shorter in length and had a smaller diameter. At 6 months, the right lower limb was 1.5 cm shorter than the left, most likely related to nutritive vessels malformations. The discrepancy was even more pronounced at the age of 9 months. This leg-length asymmetry can lead to severe functional limitations in the future.

Successful Treatment of Unilateral Klippel-Trenaunay Syndrome With Pulsed-Dye Laser in a 2-Week Old Infant

Introduction: Klippel-Trenaunay syndrome (KTS) is a rare congenital mesodermal abnormality characterized by varicose veins, cutaneous capillary malformation, as well as bone and soft tissue hypertrophy. Case Report: A 2-week-old female infant presented to our clinic because of vascular nevus and progressive enlargement of her right extremities and trunk since birth. The patient was treated with 595-nm pulsed-dye laser (PDL). Her port-wine stain (PWS) disappeared completely after third PDL session and the soft tissue hypertrophy stopped. The patient experienced neither recurrence nor any change in size after 7 years of follow up. Conclusion: PDL can treat KTS completely with no reccurence if it is used in "early stage" of disease.

Growing skull hemangioma: first and unique description in a patient with Klippel-Trénaunay-Weber syndrome

We present the first and unique case of a rapid-growing skull hemangioma in a patient with Klippel–Trénaunay–Weber syndrome. This case report provides evidence that not all rapid-growing, osteolytic skull lesions need to have a malignant character but certainly need a histopathological verification. This material offers insight into the list of rare pathological diagnoses in an infrequent syndrome.

Venous Thromboembolism in Pediatric Vascular Anomalies

The presence of a vascular anomaly suggests that capillaries, veins, arteries, and/or lymphatic vessels have demonstrated abnormal development and growth. Often dilated and misshaped, these vessels augment normal flow of blood and lymphatic fluids that increases the overall risk to develop intralesional thrombosis. Abnormal endothelial and lymphoendothelial cells activate hemostasis and hyperfibrinolytic pathways through poorly understood mechanisms, which contribute to the development of localized intravascular coagulopathy. Vascular malformations, tumors, and complex combined syndromes demonstrate varying degrees of prothrombotic activity and consumptive coagulopathy depending on the vessels involved and the pattern and extent of abnormal growth. The clinical impact of venous thromboembolism in pediatric vascular anomalies varies from painful syndromes that disrupt quality of life to life-threatening embolic disease. There remains little literature on the study, evaluation, and treatment of thrombosis in pediatric vascular anomalies. However, there have been great advances in our ability to image complex lesions, to surgically and interventionally augment disease, and to provide enhanced supportive care including patient education, compression therapy, and strategic use of anticoagulation.

Patterns of pediatric venous disease

BACKGROUND

The spectrum of chronic venous disease (CVD) is well documented in adults; clinical guidelines standardize diagnosis and treatment. There is a paucity of data published commenting on pediatric CVD exclusive of Klippel-Trénaunay syndrome (KTS) and post-thrombotic syndrome.

METHODS

This study aimed to define patterns of pediatric venous disease. All venous reflux studies performed on patients <18 years of age between January 2012 and June 2014 were reviewed. Study indication, patient history, clinical examination, and duplex ultrasound results were queried and described. Venous reflux parameters were compared using one-way analysis of variance.

RESULTS

Twenty patients were evaluated. All presented through the vascular surgery or multidisciplinary venous clinic at a tertiary academic medical center. Indications for referral included swelling (n = 10), varicose veins (n = 9), and rubor/acrocyanosis (n = 3); two patients carried a diagnosis of KTS. Mean age at study was 13 years (range, 5-17 years). Clinical examination revealed the following: dependent rubor (n = 3); edema (n = 9); and varicose veins or venous abnormality concerning for venous malformation (n = 9). There were no stigmata of chronic inflammation, hyperpigmentation, or ulceration; 90% of patients (n = 18) demonstrated venous reflux by duplex ultrasound interrogation. Mean right great saphenous vein (GSV) diameter was 0.49 cm (range, 0.31-0.66 cm); mean left GSV diameter was 0.55 cm (range, 0.24-0.93 cm). Adjunctive studies were often used (including magnetic resonance venography and lymphoscintigraphy). Despite the presence of venous reflux on imaging, an alternate diagnosis was made in 8 of 18 children (44%), including postural orthostatic hypotension syndrome (n = 2), vascular malformation (n = 2), lymphedema (n = 2), complex regional pain syndrome (n = 1), and acrocyanosis of disuse (n = 1). An additional case of KTS was identified. Three cases referred for varicose veins were diagnosed with venous malformation. Maximum GSV diameter and venous reflux time were compared across patients with isolated CVD, KTS, or an alternate diagnosis (as before). Whereas there was no significant difference in maximum GSV diameter, superficial venous reflux time was significantly increased in the patients with primary CVD and KTS (P = .0394).

CONCLUSIONS

The differential diagnosis for pediatric lower extremity edema and varicosities is broad; workup often requires adjunctive studies to secure the appropriate diagnosis. Often there is venous reflux present despite an alternative clinical diagnosis. Superficial venous reflux time may aid in the diagnosis of primary CVD. Whereas the clinical significance of pediatric venous reflux remains unclear, ongoing work to expand on venous parameters in healthy pediatric controls is warranted, as is additional follow-up to assess the natural history of pediatric venous disease.

Klippel-Trénaunay Syndrome: Need for Careful Clinical Classification

Klippel-Trénaunay syndrome (KTS) is a rare congenital malformation characterized by a triad of clinical presentations: (1) capillary malformations manifesting as a "port wine stain"; (2) limb hypertrophy; and (3) venous varicosities. It is distinguished from Parkes-Weber syndrome by the absence of substantial arteriovenous shunting. Due to the clinical implications of an arteriovenous fistula, differentiation between the two syndromes is important, as the prognosis and treatment greatly differ. We present a series of 5 cases of suspected KTS, while emphasizing the difficulties in distinguishing KTS from Parkes-Weber syndrome without diagnostic imaging and underscoring the importance of accurately classifying patients with the appropriate syndrome.

Endovenous laser ablation is an effective treatment for great saphenous vein incompetence in teenagers

OBJECTIVES

The current knowledge of chronic venous disease in teenagers and its treatment is very limited. The aim of the study is to present our experience and the available literature data on the treatment of varicose veins in teenagers with endovenous laser ablation of the great saphenous vein.

METHODS

Five patients, aged 15-17 years, were qualified for surgery, based on typical signs and symptoms of chronic venous disease. Minimally invasive treatment with endovenous laser ablation of the great saphenous vein was applied.

RESULTS

The technical success of surgery was achieved in all patients. Over a 2-year follow-up we did not observe any case of recanalisation of the great saphenous vein, recurrence of varicose veins, or serious complications, such as deep vein thrombosis or pulmonary embolism. One patient presented with resolving of post-operative bruising, and two cases of local numbness were transient.

CONCLUSIONS

Endovenous laser ablation of the great saphenous vein in the treatment of chronic venous disease in teenagers is effective and safe. The method provides excellent cosmetic effects, very short recovery time and high levels of patient satisfaction.

A port-wine stain in association with underlying syndrome

Klippel-Trenaunay syndrome (KTS) is a capillary-venous vascular malformation condition characterized by capillary malformation, soft tissue and bone hypertrophy, and varicosities. Here we present the case of a 29-year-old man who presented with port wine stain and recurrent ulcerations on his right leg. This leg was also larger than the left one. His condition was consistent with KTS. We discuss the pathogenesis, clinical presentation, complications, and treatment modalities of KTS.

Distinctive features of stump volume change in a fresh lower limb amputee with Parkes-Weber syndrome

A 23-year-old man with Parkes-Weber syndrome suffered ischaemia on the toes of his left foot with overactive high-shunting. The symptoms were refractory and persistent, and trans-tibial amputation was finally performed; all detectable active lesions that had been involved by arteriovenous shunts were removed. Marked stump swelling was found a couple of times postoperatively when compression treatment was absent. Despite excessive enlargement, conventional compression treatment using elastic bandages was effective in suppressing the enlargement rapidly and in controlling the stump volume. Additionally, 8 months postoperatively, stump enlargement has not recurred using silicone liner as compressive measures. We speculated that marked stump swelling may have been caused by postoperative temporal venous congestion due to the residual varicosities in the stump. Excessive volume change of the stump confused us and stagnated prosthetic rehabilitation. Recognition of such clinical characteristics will facilitate smooth and favourable prosthetic rehabilitation in fresh amputees with Parkes-Weber syndrome.

Vascularized lymph node flap transfer and lymphovenous anastomosis for klippel-trenaunay syndrome with congenital lymphedema

SUMMARY

A female patient with Klippel-Trenaunay syndrome, including hypertrophic bone and soft tissue in the forelimbs, bilateral lower limbs lymphedema, port-wine stains, and superficial veins of Servelle, was presented. The diagnosis of lymphedema was confirmed by lymphoscintigraphy and indocyanine green lymphography. The novel treatments consisted of vascularized lymph node transplantation to the left lymphedematous extremity and lymphovenous anastomosis to the right lymphedematous extremity. Significant improvements in subjective and objective clinical outcome were observed early in the postoperative period with continued improvements during the follow-up period.

Role of interventional radiologists in the management of lower extremity venous insufficiency

Lower extremity venous insufficiency affects over half of all women. Interventional radiologists should be aware of the clinical evaluation of women with venous insufficiency and classification of disease. Endovascular therapies available for treatment of lower extremity venous insufficiency include: endovenous laser ablation, radiofrequency endovascular ablation, and sclerotherapy. The interventional radiologist should be versed on which therapy to select in each clinical presentation and the procedural techniques. The authors review the role of the interventional radiologist in managing this lower extremity venous disorder.

Differential diagnoses of overgrowth syndromes: the most important clinical and radiological disease manifestations

Overgrowth syndromes comprise a heterogeneous group of diseases that are characterized by excessive tissue development. Some of these syndromes may be associated with dysfunction in the receptor tyrosine kinase (RTK)/PI3K/AKT pathway, which results in an increased expression of the insulin receptor. In the current review, four overgrowth syndromes were characterized (Proteus syndrome, Klippel-Trenaunay-Weber syndrome, Madelung's disease, and neurofibromatosis type I) and illustrated using cases from our institution. Because these syndromes have overlapping clinical manifestations and have no established genetic tests for their diagnosis, radiological methods are important contributors to the diagnosis of many of these syndromes. The correlation of genetic discoveries and molecular pathways that may contribute to the phenotypic expression is also of interest, as this may lead to potential therapeutic interventions.

Endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy in treatment of klippel-trenaunay syndrome

INTRODUCTION

Klippel-Trenaunay syndrome is composed of port-wine stain, limb hypertrophy and varicose veins.

METHODS

The two patients with Klippel-Trenaunay syndrome treated by endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy of the abnormal veins was conducted.

RESULTS

Radiofrequency thermal ablation resulted in successful occlusion of the incompetent anterior accessory great saphenous vein. Moreover, ultrasound-guided foam sclerotherapy showed complete occlusion of the residual veins. At 6 month follow-up, both patients markedly decreased leg symptoms including pain, cramping, limb swelling, and bulging of veins.

CONCLUSION

Radiofrequency thermal ablation combined with foam sclerotherapy is a minimally invasive procedure alternative to the standard invasive surgery and can be the option for saphenous ablation in Klippel-Trenaunay syndrome patients.

Sonographic identification of klippel-trenaunay-weber syndrome

Klippel-Trenaunay-Weber syndrome is a rare cutaneous vascular disorder characterized by the presence of multiple hemangiomata, arteriovenous fistulas, and limb hypertrophy. We report the prenatal sonographic findings in a case of Klippel-Trenaunay-Weber (KTW) syndrome including fetal limb hypertrophy and large subcutaneous cystic lesions. Prenatal diagnosis is possible by ultrasound examination and recognition important for prevention of complications and future management.