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Foster M, Roy A, Kumar G. Large birth mark and unilateral swelling of the lower extremity in a young teenager. BMJ Case Rep 2024; 17:e258892. [PMID: 38702071 PMCID: PMC11085769 DOI: 10.1136/bcr-2023-258892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024] Open
Abstract
We describe an early adolescent male who was diagnosed with vascular malformation associated with unilateral limb overgrowth based on the clinical findings of a persistent port-wine stain since birth and gradually progressing right lower limb oedema since early childhood. Clinicians should keep in mind to clinically evaluate such malformations in detail, as well as contemplate genetic testing in patients presenting with a large port-wine stain at birth, particularly if well demarcated and lateral in a lower extremity.
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Affiliation(s)
- Michael Foster
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Aparna Roy
- Paediatrics, Case Western Reserve University Hospital, Cleveland, Ohio, USA
| | - Gurinder Kumar
- Paediatrics, Case Western Reserve University Hospital, Cleveland, Ohio, USA
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2
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Nguyen R, Murra A, Capdeville M. Chronic Thromboembolic Pulmonary Hypertension Due to a Rare Anterior Mediastinal Venous Malformation. J Cardiothorac Vasc Anesth 2024; 38:552-557. [PMID: 36528502 DOI: 10.1053/j.jvca.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Rachel Nguyen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Ali Murra
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Michelle Capdeville
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.
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3
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Lo CY, Chen KB, Chen LK, Chiou CS. Massive pulmonary embolism in Klippel-Trenaunay syndrome after leg raising: A case report. World J Clin Cases 2023; 11:4133-4141. [PMID: 37388793 PMCID: PMC10303615 DOI: 10.12998/wjcc.v11.i17.4133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/27/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder characterized by a combination of capillary malformations, soft-tissue or bone hypertrophy, and varicose veins or venous malformations. The syndrome predisposes patients to hypercoagulable states, including venous thromboembolism and pulmonary embolism (PE).
CASE SUMMARY A 12-year-old girl with KTS was scheduled excision of verrucous hyperkeratosis in the left foot and posterior aspect of the left leg and left thigh and excision of a cutaneous hemangioma in the right buttock. After induction, the surgeon elevated the patient’s leg for sterilization, whereupon she experienced a massive PE and refractory cardiac arrest. Extracorporeal membrane oxygenation (ECMO) was performed after prolonged resuscitation, and she had a return of spontaneous circulation. After this episode, the patient was discharged without any neurologic complications.
CONCLUSION The mechanism of PE, a lethal disease, involves a preexisting deep vein thrombosis that is mechanically dislodged by compression or changing positions and travels to the pulmonary artery. Therefore, patients predisposed to PE should be prescribed prophylactic anticoagulants. If the patient has unstable vital signs, resuscitation should be started immediately, and extracorporeal cardiopulmonary resuscitation should be considered in settings with existing ECMO protocols, expertise, and equipment. Awareness of PE in patients with KTS while leg raising for sterilization is critical.
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Affiliation(s)
- Chih-Yu Lo
- Department of Anesthesiology, China Medical University Hospital, Taichung 40447, Taiwan
| | - Kuen-Bao Chen
- Department of Anesthesiology Pain Service and Critical Care Medicine, China Medical University Hospital, Taichung 40447, Taiwan
| | - Li-Kuei Chen
- Department of Anesthesiology, China Medical University Hospital, Taichung 40447, Taiwan
| | - Chiuan-Shiou Chiou
- Department of Anesthesiology, China Medical University Hospital, Taichung 40447, Taiwan
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Senthilkumar VA, Kohli P, Mishra C, Mamchisetti K. Ocular features in a patient presenting with a rare combination of multiple phakomatoses. BMJ Case Rep 2022; 15:e252746. [PMID: 36384883 PMCID: PMC9670835 DOI: 10.1136/bcr-2022-252746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Phakomatoses are a group of congenital disorders characterised by hamartomatous lesions of the skin as well as the central and peripheral nervous systems. The presence of naevus flammeus or port-wine stain is a characteristic feature of many such disorders including Sturge-Weber syndrome (SWS), Klippel-Trenaunay syndrome (KTS) and Phakomatosis pigmentovascularis (PPV).We describe the ocular findings in a patient with coexisting PPV, SWS and KTS.
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Affiliation(s)
| | - Piyush Kohli
- Department of Vitreoretinal services, C.L. Gupta Eye Institute, Moradabad, Uttar Pradesh, India
| | - Chitaranjan Mishra
- Department of Glaucoma, Aravind Eye Hospital, Madurai, Tamil Nadu, India
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5
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Deep vein thrombosis in the setting of Klippel-Trenaunay syndrome and sirolimus treatment. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:524-528. [PMID: 34401617 PMCID: PMC8358289 DOI: 10.1016/j.jvscit.2021.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/29/2021] [Indexed: 01/19/2023]
Abstract
Klippel-Trenaunay syndrome (KTS) is a congenital vascular disorder characterized by the triad of cutaneous capillary malformation, lymphatic and venous anomalies, and soft tissue and bone overgrowth. Sirolimus is a mechanistic target of rapamycin inhibitor used as an immunosuppressive drug. It has also been used to improve and treat vascular malformations that can predispose to intravascular coagulopathy. We have described the case of a patient with KTS receiving a therapeutic anticoagulation dose, for whom sirolimus was initiated, and who had presented with an extensive venous thromboembolism. Correlations between the use of sirolimus in patients with KTS are limited, and cautious use and monitoring could be necessary.
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Abstract
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.
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Affiliation(s)
- Bernard A Cohen
- Division of Pediatric Dermatology, Johns Hopkins Medical Institutions, 200 N. Wolfe Street, Baltimore, MD 21287, USA.
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7
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Cyrek AE. Eine außergewöhnliche Therapie der Vena-iliaca-externa-Hypoplasie bei einer Patientin mit Klippel-Trénaunay-Syndrom – ein Fallbericht. PHLEBOLOGIE 2020. [DOI: 10.1055/a-1134-8807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
ZusammenfassungDas 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.
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Affiliation(s)
- Anna Ewa Cyrek
- Sektion Gefäßchirurgie und Endovaskuläre Chirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen
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Asghar F, Aqeel R, Farooque U, Haq A, Taimur M. Presentation and Management of Klippel-Trenaunay Syndrome: A Review of Available Data. Cureus 2020; 12:e8023. [PMID: 32528762 PMCID: PMC7282379 DOI: 10.7759/cureus.8023] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Fahham Asghar
- Neurology, Dow Medical College, Dow University of Health Sciences, Karachi, PAK
| | - Ramsha Aqeel
- Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, PAK
| | - Umar Farooque
- Neurology, Dow Medical College, Dow University of Health Sciences, Karachi, PAK
| | | | - Muhammad Taimur
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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Jeong SH, Joo D, Lim TJ, Lee YJ. Newly Diagnosed Klippel-Trenaunay Syndrome Presenting with Rectal Polyposis in a Male Pediatric Patient: A Case Report. Pediatr Gastroenterol Hepatol Nutr 2020; 23:115-120. [PMID: 31988883 PMCID: PMC6966219 DOI: 10.5223/pghn.2020.23.1.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/30/2019] [Indexed: 01/19/2023] Open
Abstract
Klippel-Trenaunay syndrome (KTS) is a rare disorder characterized by a triad of abnormal bone and soft tissue growth, the presence of a port-wine stain, and venous malformations. Gastrointestinal (GI) manifestations of KTS are relatively common and generally do not cause significant problems. However, persistence can lead to chronic GI blood loss or even massive bleeding in rare cases. The majority of the severe GI manifestations associated with KTS present as vascular malformations around the GI tract and exposed vessels can lead to serious bleeding into the GI tract. Herein, we report a case of a 16-year-old boy with severe iron deficiency anemia who was previously misdiagnosed as hemorrhoid due to small amount of chronic bleeding. The actual cause of chronic GI bleeding was from an uncommon GI manifestation of KTS as rectal polyposis.
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Affiliation(s)
- Seong Hee Jeong
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Donghoon Joo
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Taek Jin Lim
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Yeoun Joo Lee
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
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10
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Klippel-Trenaunay syndrome as a rare cause of chronic thromboemboembolic pulmonary hypertension. Respir Med Res 2019; 76:48-53. [PMID: 31557688 DOI: 10.1016/j.resmer.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
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.
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Abstract
Ongoing discovery regarding the origin and treatment of vascular anomalies requires standardized nomenclature which itself must undergo iterative updating. This article introduces the 2018 International Society for the Study of Vascular Anomalies (ISSVA) classification, emphasizing the biologic basis of vascular anomalies, summarizing the key features of commonly encountered entities, and serving as a foundation for subsequent articles presented herein. Vascular tumors are discussed to highlight their distinction from vascular malformations which will receive greater attention with respect to management and technical considerations within the issue.
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Affiliation(s)
- Eric J Monroe
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington, Seattle, WA.
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12
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Keppler-Noreuil KM, Lozier J, Oden N, Taneja A, Burton-Akright J, Sapp JC, Biesecker LG. Thrombosis risk factors in PIK3CA-related overgrowth spectrum and Proteus syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:571-581. [PMID: 31490637 DOI: 10.1002/ajmg.c.31735] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/27/2019] [Accepted: 07/30/2019] [Indexed: 01/19/2023]
Abstract
Increased risk of thromboembolism has been recognized in individuals with mosaic overgrowth disorders, Proteus syndrome (PS) and PIK3CA-related overgrowth spectrum (PROS), including Klippel-Trenaunay syndrome and CLOVES syndrome. PS and PROS have distinct, yet overlapping clinical findings and are caused by somatic pathogenic variants in the PI3K/AKT gene signaling pathway. PS is caused by a single somatic activating AKT1 c.49G > A p.E17K variant while PROS can be caused one of multiple variants in PIK3CA. The role of prothrombotic factors, endothelial cell adhesion molecules, and vascular malformations in both PS and PROS have not been previously investigated. A pilot study of prospective clinical and laboratory evaluations with the purposes of identifying potential risk factors for thrombosis was conducted. Doppler ultrasounds and magnetic resonance angiogram/ venography (MRA/MRV) scans identified vascular malformations in PS and PROS that were not appreciated on physical examination. Abnormal D-dimers (0.60-2.0 mcg/ml) occurred in half of individuals, many having vascular malformations, but no thromboses. Soluble vascular endothelial markers, including thrombomodulin, soluble vascular adhesion molecule (sVCAM), soluble intercellular adhesion molecule (sICAM), E-selectin, and P-selectin were significantly higher in PS and PROS compared to controls. However, no single attribute was identified that explained the risk of thrombosis. Predisposition to thrombosis is likely multifactorial with risk factors including chronic stasis within vascular malformations, stasis from impaired mobility (e.g., following surgery), decreased anticoagulant proteins, and effects of AKT1 and PIK3CA variants on vascular endothelium. Based on our findings, we propose clinical recommendations for surveillance of thrombosis in PS and PROS.
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Affiliation(s)
- Kim M Keppler-Noreuil
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Jay Lozier
- Department of Laboratory Medicine, Warren Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Neal Oden
- Department of Biostatistics, The EMMES Corporation, Rockville, Maryland
| | - Anjali Taneja
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Jasmine Burton-Akright
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Julie C Sapp
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Leslie G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
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Bittles M, Jodeh DS, Mayer JLR, Gallant M, Rottgers SA. Laser ablation of embryonic veins in children. Pediatr Int 2019; 61:358-363. [PMID: 30742735 DOI: 10.1111/ped.13804] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/29/2018] [Accepted: 02/07/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Klippel-Trenaunay syndrome (KTS) and related overgrowth syndromes are rare conditions that often present to academic pediatric units and multidisciplinary vascular anomaly clinics. These conditions are commonly associated with abnormalities of the superficial and deep venous structures and carry an increased risk of venous thromboembolism. METHODS A retrospective chart review was completed of all patients treated at Johns Hopkins All Children's Hospital with endovenous laser ablation therapy (EVLT) for management of dilated embryonic veins in the setting of limb overgrowth. RESULTS Three patients with limb overgrowth underwent EVLT between 2015 and 2017. All patients had successful occlusion of the targeted veins on post-procedure imaging. One patient developed a cellulitis successfully treated with oral antibiotics. CONCLUSIONS Endovenous laser ablation therapy is a well-tolerated and safe procedure for prophylactic closure of abnormal superficial embryonic veins. This study supports the use of this technique in managing increased thromboembolic risk in this unique patient population and recognizes the need for a long-term study to determine its efficacy.
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Affiliation(s)
- Mark Bittles
- Department of Radiology, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Diana S Jodeh
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Jennifer L R Mayer
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Michael Gallant
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - S Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
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Zhai J, Zhong ME, Shen J, Tan H, Li Z. Kyphoscoliosis with Klippel-Trenaunay syndrome: a case report and literature review. BMC Musculoskelet Disord 2019; 20:10. [PMID: 30611239 PMCID: PMC6320630 DOI: 10.1186/s12891-018-2393-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/21/2018] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Jiliang Zhai
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Min-Er Zhong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jianxiong Shen
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Haining Tan
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Zheng Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
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15
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Almeida FT, Caldas R, Duarte MDL, Brito C. Port-wine stain as a clue for two rare coexisting entities. BMJ Case Rep 2018; 2018:bcr-2018-225721. [DOI: 10.1136/bcr-2018-225721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Abstract
Vascular anomalies are classified as tumors and malformations depending on their clinical characteristics, pathological diagnosis and recent genomic information. Diagnosis can still be challenging because of the heterogeneity of clinical presentation. Thus, the best care is provided by an interdisciplinary team of specialists. An updated classification system has helped provide more consistent terminology with the addition of new diagnoses and genomic discovery. Historically, treatment of vascular anomalies was primarily surgical and or interventional with limited medical therapies. The field of vascular anomalies lacked prospective clinical trials in both medical treatments as well as surgical and interventional therapeutic options. Recent interdisciplinary collaboration has led to collaborative studies in which short- and long-term outcomes are being prospectively evaluated. Specifically, discoveries of pharmacologic agents effective in treating vascular anomalies have broadened our medical therapeutic options, which has led to innovative approaches in combined treatment of vascular anomalies and has stressed the need to prospectively assess long-term outcomes and sequelae for these patients which has been lacking in this field.
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Affiliation(s)
- Denise M Adams
- Department of Medicine, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, MA; Division of Hematology, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Steven J Fishman
- Department of Medicine, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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17
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Keppler-Noreuil KM, Lozier JN, Sapp JC, Biesecker LG. Characterization of thrombosis in patients with Proteus syndrome. Am J Med Genet A 2017. [PMID: 28627093 DOI: 10.1002/ajmg.a.38311] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Kim M Keppler-Noreuil
- Medical Genomics Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Jay N Lozier
- Department of Laboratory Medicine, Warren Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Julie C Sapp
- Medical Genomics Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Leslie G Biesecker
- Medical Genomics Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
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Mehta V, Bhatia K, Dave AM, Depew ZS. A 39-Year-Old Pregnant Woman with Pulmonary Emboli on Long Term Anticoagulation. Cureus 2017; 9:e1356. [PMID: 28721324 PMCID: PMC5510980 DOI: 10.7759/cureus.1356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
We present the case of a 39-year-old pregnant woman with Klippel-Trenaunay syndrome (KTS). We demonstrate the risks of multiple, co-existing pro-thrombotic states (pregnancy, KTS), discuss complications of KTS (deep venous thromboembolisms and pulmonary emboli) and highlight general and disease-specific preventive measures against venous thromboembolic events (VTE). KTS is a rare condition and it's co-existence with pregnancy and VTEs is rarer still.
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Affiliation(s)
| | | | - Amanda M Dave
- School of Medicine, Creighton University Medical Center
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Sepúlveda P, Zavala A, Zúñiga P. Factors associated with thrombotic complications in pediatric patients with vascular malformations. J Pediatr Surg 2017; 52:400-404. [PMID: 27884452 DOI: 10.1016/j.jpedsurg.2016.10.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 10/21/2016] [Accepted: 10/29/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Thrombosis is an uncommon disorder in children. Patients with slowflow vascular malformations have higher risk of developing localized intravascular coagulation, which is closely related to the presence of thrombotic events. These episodes cause pain, can be recurrent and determine a clear deterioration in the quality of life. Moreover, serious complications such as pulmonary thromboembolism and eventually death have been described. The aim of the present study is to identify clinical and laboratory risk factors associated with thrombotic events in pediatric patients with vascular malformations. METHODS Case-Control study. Clinical records of patients who consulted the vascular anomalies study group (VASG). This group carries out interdisciplinary assessment of patients with vascular malformations. From June 2008 to December 2014, 110 patients were assessed of whom 46 patients met the inclusion criteria, with half of them presenting a thrombotic complication and the others not, these latter serving as controls. Statistical analysis included multivariate logistic regression analysis to determine major risk factors for thrombosis. RESULTS In the bivariate analysis we found a significant association between increased levels of Ddimer and thrombotic complications (OR 17.1 [95% CI 3.95-73.95; p<0.01]). In addition, a surface area≥10cm2 (OR 6.18 [95% CI 1.59-23.99; p<0.01]) and the presence of palpable phleboliths (OR 20.17 [95% CI 2.32-165.77; p<0.01]) were associated with a significant higher risk of thrombosis. Multivariate analysis identified older age (OR 1.33; p=0.013), a surface area≥10cm2 (OR 8.19; p=0.042) and palpable phleboliths (OR 85.29; p<0.01) as significant risk factors. CONCLUSIONS Our study suggests the existence of clinical factors associated with higher risk of thrombotic complications, such as the extent of the malformation, palpable phleboliths and increased age among children with vascular malformations.
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Affiliation(s)
| | - Alejandro Zavala
- Departament of Surgery, Pediatric Surgery Unit, Pontificia Universidad Católica de, Chile
| | - Pamela Zúñiga
- Departament of Pediatrics, Pediatric Hematology-Oncology Unit, Pontificia Universidad Católica de, Chile
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Nakano TA, Zeinati C. Venous Thromboembolism in Pediatric Vascular Anomalies. Front Pediatr 2017; 5:158. [PMID: 28791278 PMCID: PMC5522837 DOI: 10.3389/fped.2017.00158] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/30/2017] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Denver, CO, United States
| | - Chadi Zeinati
- Vascular Anomalies Center, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
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Upadhyay H, Sherani K, Vakil A, Babury M. A case of recurrent massive pulmonary embolism in Klippel-Trenaunay-Weber syndrome treated with thrombolytics. Respir Med Case Rep 2016; 17:68-70. [PMID: 27141435 PMCID: PMC4821330 DOI: 10.1016/j.rmcr.2016.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 12/05/2022] Open
Abstract
Klippel – Trenaunay – Weber syndrome (KTWS) is a congenital condition characterized by a triad of capillary malformations of the skin, soft tissue and bone hypertrophy resulting in limb enlargement, and abnormalities of arteriovenous and lymphatic systems of the affected limb. In this case, we present a patient with KTWS receiving chronic anticoagulation that had a massive pulmonary embolism and was successfully treated with thrombolytic therapy. The purpose of this case is to educate readers about this uncommon condition and to increase awareness, recognition and timely treatment of its most common complications, namely thrombosis and pulmonary embolism.
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Affiliation(s)
- Hinesh Upadhyay
- Department of Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY, United States
| | - Khalid Sherani
- Department of Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY, United States
| | - Abhay Vakil
- Department of Pulmonary Medicine, Jamaica Hospital Medical Center, Jamaica, NY, United States
| | - Mohammed Babury
- Department of Pulmonary Medicine, Jamaica Hospital Medical Center, Jamaica, NY, United States
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22
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Chu ST, Han YH, Koh JA, Kim SJ, Lee HC, Kim SE, Shin YC, Sir JJ, Choi SM, Joo SB. A Case of Klippel-Trenaunay Syndrome with Acute Submassive Pulmonary Thromboembolism Treated with Thrombolytic Therapy. J Cardiovasc Ultrasound 2016; 23:266-70. [PMID: 26755937 PMCID: PMC4707314 DOI: 10.4250/jcu.2015.23.4.266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/31/2015] [Accepted: 11/18/2015] [Indexed: 11/22/2022] Open
Abstract
Klippel-Trenaunay syndrome is a rare congenital mesodermal abnormality characterized by varicose veins, cutaneous hemangiomas, soft tissue and bony hypertrophy of limb. Potential complications such as deep venous thrombosis and pulmonary thromboembolism have not been reported in Korea to date. We demonstrate the case of a 48-year-old woman with Klippel-Trenaunay syndrome with extensive varicose veins on right lower limb, hypertrophy of left big toe and basilar artery tip aneurysm, complicated with acute submassive pulmonary thromboembolism treated successfully with intravenous thrombolytic therapy.
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Affiliation(s)
- Seong-Taek Chu
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Yung-Hee Han
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Jung-A Koh
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Seon-Jae Kim
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Hak-Cheol Lee
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Si-Eun Kim
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Yong-Chul Shin
- Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Jung Ju Sir
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Seung Min Choi
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
| | - Shin Bae Joo
- Department of Internal Medicine, National Medical Center, Seoul, Korea.; Cardiovascular Center, National Medical Center, Seoul, Korea
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23
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Klippel-Trenaunay Syndrome with Extensive Lymphangiomas. Case Rep Pediatr 2015; 2015:581394. [PMID: 26587303 PMCID: PMC4637471 DOI: 10.1155/2015/581394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 10/02/2015] [Accepted: 10/08/2015] [Indexed: 01/19/2023] Open
Abstract
Klippel-Trenaunay syndrome (KTS) is a rare disorder characterized by the triad of vascular malformations, venous varicosities, and bone and soft-tissue hypertrophy. We present a case of Klippel-Trenaunay syndrome with limb hypertrophy, port-wine stains, lymphangiomas, and venous varicosities in the limbs.
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Klippel-trénaunay syndrome with intracranial arteriovenous malformation: a rare presentation. Case Rep Radiol 2014; 2014:202160. [PMID: 24653849 PMCID: PMC3932826 DOI: 10.1155/2014/202160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 11/12/2013] [Indexed: 01/19/2023] Open
Abstract
Klippel-Trénaunay syndrome (KTS) is a rare vascular congenital anomaly affecting less than 200,000 people in the United States. Vascular malformations associated with KTS tend to affect slow flow systems: venous, capillary, and lymphatic systems. The nature of the syndrome leads to a higher risk for the development of arteriovenous malformations. Our case presentation describes a patient with KTS and an associated rare presentation of intraventricular arteriovenous malformation (AVM).
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25
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Ndzengue A, Rafal RB, Balmir S, Rai DB, Jaffe EA. Klippel-trenaunay syndrome: an often overlooked risk factor for venous thromboembolic disease. Int J Angiol 2013; 21:233-6. [PMID: 24293983 DOI: 10.1055/s-0032-1328969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Klippel-Trenaunay syndrome (KTS) is a congenital condition redefined by Oduber et al (2008) by the coexistence of vascular malformations and disturbed soft tissue or bony growth, including hypertrophy or hypotrophy in the same or opposite sides of the body. The anomalies may involve part of a limb, a whole limb, a limb girdle, or a hemibody. Vascular malformations may involve veins, capillaries, or lymphatics although venous or capillary malformations are essential for the diagnosis. Associated venous anomalies include dysplasia, valvular malformations, and varicosities. Congenital venous anomalies are often associated with disturbances of blood flow and should be considered as prothrombotic states. However, such anomalies are not considered in Wells scores and used to determine the risk for venous thromboembolism (VTE). We present the case of a male with unrecognized crossed dissociated form of KTS and unsuspected VTE. The pathophysiology and the treatment of VTE in KTS are discussed. We suggest physicians to be aware of KTS and that its recognition in a critically ill patient should prompt consideration for appropriate prophylaxis for high-risk category for VTE. Dedicated duplex sonography should be obtained if VTE is suspected. We also suggest a modification of the Wells scores to reflect the association of KTS and VTE.
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Affiliation(s)
- Albert Ndzengue
- Department of medicine, Interfaith Medical Center, Brooklyn, New York
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26
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Ohmori H, Ochi F, Tanuma N, Ohnuki E, Yamasaki M, Takesue H, Kan M, Matsumoto N, Sumimoto R, Harada A. Deep vein thrombosis in patients with severe motor and intellectual disabilities. Ann Vasc Dis 2013; 6:694-701. [PMID: 24386017 DOI: 10.3400/avd.oa.13-00090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/22/2013] [Indexed: 01/29/2023] Open
Abstract
Most patients with severe motor and intellectual disabilities (SMID) have restricted mobility capability and have been bedridden for long periods because of paralysis of the extremities caused by abnormal muscular tonicity due to cerebral palsy and developmental disabilities, and such patients are associated with a high risk for the complications of deep vein thrombosis (DVT). Here, we report 8 patients (34.8%) with DVT among 23 patients with SMID during prolonged bed rest. However, we did not detect thrombosis in the soleal veins, finding it mostly in the superficial femoral and common femoral veins. Regarding laboratory data for the coagulation system, there were no cases with D-dimer above 5 µg/ml. Concerning sudden death in patients with SMID, we have to be very careful of the possibility of pulmonary thromboembolism due to DVT. Therefore, we should consider the particularities of an underdeveloped vascular system from underlying diseases for the evaluation of DVT in patients with SMID. A detailed study of DVT as a vascular complication is very important for smooth medical care of SMID and compression Doppler ultrasonography of the lower extremities, as noninvasive examination, is very helpful. (English translation of Jpn J Phlebol 2012; 23: 17-24).
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Affiliation(s)
- Hiromitsu Ohmori
- Department of Pediatrics, National Hospital Organization Yanai Medical Center, Yanai, Yamaguchi, Japan
| | - Fumihiro Ochi
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Naoyuki Tanuma
- Department of Pediatrics, Tokyo Metropolitan Fuchu Center for the Disabled, Fuchu, Tokyo, Japan
| | - Eiichi Ohnuki
- Department of Neurology, National Hospital Organization Yanai Medical Center, Yanai, Yamaguchi, Japan
| | - Masami Yamasaki
- Department of Neurology, National Hospital Organization Yanai Medical Center, Yanai, Yamaguchi, Japan
| | - Hiroko Takesue
- Department of Laboratory, National Hospital Organization Yanai Medical Center, Yanai, Yamaguchi, Japan
| | - Miki Kan
- Department of Medical Laboratory, Ehime Prefectural Central Hospital, Matsuyama, Ehime, Japan
| | - Nobuo Matsumoto
- Department of Internal Medicine, National Hospital Organization Yanai Medical Center, Yanai, Yamaguchi, Japan
| | - Ryo Sumimoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yanai, Yamaguchi, Japan
| | - Akira Harada
- Department of Neurology, National Hospital Organization Yanai Medical Center, Yanai, Yamaguchi, Japan
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27
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Management of disseminated intravascular coagulopathy with direct factor Xa inhibitor rivaroxaban in Klippel–Trénaunay syndrome. Blood Coagul Fibrinolysis 2013; 24:766-70. [DOI: 10.1097/mbc.0b013e3283626238] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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28
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Klippel-Trenaunay Syndrome Causing Life-Threatening GI Bleeding: A Case Report and Review of the Literature. Case Rep Gastrointest Med 2013; 2013:813653. [PMID: 23862081 PMCID: PMC3686071 DOI: 10.1155/2013/813653] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 05/16/2013] [Indexed: 01/19/2023] Open
Abstract
Klippel-Trenaunay syndrome (KTS) is a rare congenital syndrome of vascular malformations and soft tissue and bone hypertrophy. Vascular malformations can affect multiple organ systems. Involvement of the gastrointestinal (GI) tract is uncommon in KTS, but it can be a source of life-threatening bleeding. We report a case of a 32-year-old male with a known diagnosis of KTS who presented with a life-threatening rectal bleeding and was treated with proctosigmoidectomy and massive blood products transfusion. He expired after a long hospitalization. We then review the literature on KTS and management of some of its complications.
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29
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Sing AC, Webb JL, Low DW, Chen AE. Pulmonary emboli associated with isolated lower-extremity venous malformation: a case report. Pediatr Emerg Care 2013; 29:371-3. [PMID: 23462395 DOI: 10.1097/pec.0b013e31828547a9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Alan C Sing
- Department of Pediatrics, The Children's Hospital of Philadelphia, PA 19104, USA.
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30
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McRae MY, Adams S, Pereira J, Parsi K, Wargon O. Venous malformations: Clinical course and management of vascular birthmark clinic cases. Australas J Dermatol 2012; 54:22-30. [DOI: 10.1111/j.1440-0960.2012.00959.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 08/19/2012] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - John Pereira
- Department of Medical Imaging; Sydney Children's Hospital; Randwick
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31
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Abstract
Unlike in adults, pulmonary embolism (PE) is an infrequent event in children. It has a marked bimodal distribution during the paediatric years, occurring predominantly in neonates and adolescents. The most important predisposing factors to PE in children are the presence of a central venous line (CVL), infection, and congenital heart disease. Clinical signs of PE are non-specific in children or can be masked by underlying conditions. Diagnostic testing is necessary in children, especially with the lack of clinical prediction rules. Recommendations for tests are derived from adult studies with ventilation/perfusion (V/Q) scintigraphy being well established. There exists an increasing role for computerised tomography pulmonary angiography (CTPA) and magnetic resonance pulmonary angiography (MRPA). Thrombotic events in children are initially treated with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). For the extended anticoagulant therapy LMWH or vitamin K antagonists can be used with duration of treatment recommendations extrapolated from adult data. Mortality rates for PE in children are reported to be around 10%, with death usually related to the underlying disease processes. Exact data about recurrence risk in children is unknown. Because of the difference in aetiology, presentation, diagnostic methods and treatment between adults and children further research is necessary to assess the validity of recommendations for children.
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Affiliation(s)
- F Nicole Dijk
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia
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32
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Lee CH, Turcios NL, Cohen BA. Pulmonary complications of dermatological disorders. Paediatr Respir Rev 2012; 13:50-6. [PMID: 22208794 DOI: 10.1016/j.prrv.2011.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Catherine H Lee
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Douma RA, Oduber CE, Gerdes VE, van Delden OM, van Eck-Smit BL, Meijers JC, van Beers EJ, Bouma BJ, van der Horst CM, Bresser P. Chronic pulmonary embolism in Klippel-Trenaunay syndrome. J Am Acad Dermatol 2012; 66:71-7. [DOI: 10.1016/j.jaad.2010.12.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 11/29/2010] [Accepted: 12/04/2010] [Indexed: 01/19/2023]
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Diagnosis and management of extensive vascular malformations of the lower limb: part II. Systemic repercussions [corrected], diagnosis, and treatment. J Am Acad Dermatol 2011; 65:909-23; quiz 924. [PMID: 22000871 DOI: 10.1016/j.jaad.2011.03.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Klippel-Trenaunay-Syndrom. Monatsschr Kinderheilkd 2010. [DOI: 10.1007/s00112-010-2337-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
This article discusses pneumothorax, pneumomediastinum, and pulmonary embolism in pediatric practice. Although children appear to have better outcomes than adults, the risk factors are substantial. Topics covered include the pathophysiology incidence, presentation, diagnosis, and management of these diseases.
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Affiliation(s)
- Nakia N Johnson
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Suite A-210, Houston, TX 77030, USA
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39
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Therapy of Acute Massive Pulmonary Embolism Associated With Klippel–Trenaunay Syndrome. Ann Vasc Surg 2010; 24:1138.e5-7. [DOI: 10.1016/j.avsg.2010.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 03/23/2010] [Accepted: 06/23/2010] [Indexed: 11/22/2022]
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40
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Abstract
The aim of this review was to discuss the current knowledge on aetiopathogenesis, diagnosis and therapeutic management of venous malformations (VMs). VMs are slow-flow vascular anomalies. They are simple, sporadic or familial (cutaneomucosal VMs or glomuvenous malformations), combined (e.g. capillaro-venous and capillaro-lymphaticovenous malformations) or syndromic (Klippel-Trenaunay, blue rubber bleb naevus and Maffucci). Genetic studies have identified causes of familial forms and of 40% of sporadic VMs. Another diagnostic advancement is the identification of elevated D-dimer level as the first biomarker of VMs within vascular anomalies. Those associated with pain are often responsive to low-molecular-weight heparin, which should also be used to avoid disseminated intravascular coagulopathy secondary to intervention, especially if fibrinogen level is low. Finally, development of a modified sclerosing agent, ethylcellulose-ethanol, has improved therapy. It is efficient and safe, and widens indications for sclerotherapy to sensitive and dangerous areas such as hands, feet and periocular area.
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Affiliation(s)
- Anne Dompmartin
- Université de Caen Basse Normandie, CHU Caen, Department of Dermatology, Caen (France)
| | - Miikka Vikkula
- Université catholique de Louvain, de Duve Institute, Laboratory of Human Molecular Genetics, B-1200 Brussels, Belgium
| | - Laurence M Boon
- Université catholique de Louvain, de Duve Institute, Laboratory of Human Molecular Genetics, B-1200 Brussels, Belgium
- Université catholique de Louvain, Cliniques universitaires St Luc, Center for Vascular Anomalies, Division of Plastic Surgery, B-1200 Brussels, Belgium
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41
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Oishi SN, Ezaki M. Venous thrombosis and pulmonary embolus in pediatric patients with large upper extremity venous malformations. J Hand Surg Am 2010; 35:1330-3. [PMID: 20638199 DOI: 10.1016/j.jhsa.2010.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 05/03/2010] [Accepted: 05/10/2010] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Scott N Oishi
- Department of Hand Surgery, Texas Scottish Rite Hospital for Children, Dallas, TX 75219, USA.
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42
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Star A, Fuller CE, Landas SK. Intracranial aneurysms in klippel-trenaunay/weber syndromes: case report. Neurosurgery 2010; 66:E1027-8; discussion E1028. [PMID: 20404675 DOI: 10.1227/01.neu.0000368392.69904.be] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE We present a comprehensive review of intracranial aneurysms in Klippel-Trenaunay and Klippel-Trenaunay-Weber syndromes (KTS/KTWS), and examine factors influencing the risks of surgery vs conservative management. CLINICAL PRESENTATION A 58-year-old physician with KTS affecting the right extremities presented with left hemispheric cerebellar stroke and was discovered to harbor four intracranial aneurysms of the posterior circulation: fusiform mid and distal BA (2.6 x 2 x 2 cm), fusiform right proximal P1 (2 x 1.3 x 1.3 cm), fusiform right distal P1 (2.8 x 2.7 x 2 cm), and saccular left distal posterior inferior cerebellar artery (2.5 x 2.5 x 2.5 cm). Ten years later he had an infarct in the paramedian distribution of the basilar artery and a right internal capsule stroke. Two months later, he developed hydrocephalus, ultimately presenting in status epilepticus 4 months later secondary to ongoing aneurysm expansion and mass effect. INTERVENTION Systemic anticoagulation for acute thrombosis with possible distal arterioarterial embolization from giant P1 aneurysms. Ventriculoperitoneal shunting for hydrocephalus. The patient died within 9 days after admission and 10 years after the initial discovery of aneurysms. CONCLUSION Strict control of modifiable risk factors compromising vascular integrity and periodic neuroimaging are warranted in KTS/KTWS patients. KTS/KTWS patients are hypercoagulable, and may be predisposed to aneurysm thrombosis with increased risk for distal arterial microembolization. Stroke-related morbidity secondary to distal arterioarterial aneurysm thrombus embolization and acute aneurysm thrombosis may be decreased with systemic anticoagulation in this patient population. KTS/KTWS patients have significantly higher rates of DVT and PE than the general population, and should be classified in the high-risk category for venous thromboembolism prophylaxis. Both endovascular and open cerebrovascular techniques have been used successfully in KTS/KTWS patients with intracranial aneurysms.
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Affiliation(s)
- Ava Star
- College of Medicine, SUNY Upstate, Syracuse, New York 13210, USA.
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Johnson JN, Driscoll DJ, McGregor CGA. Pulmonary thromboendarterectomy in adolescents and young adults. Pediatr Pulmonol 2010; 45:614-8. [PMID: 20503288 DOI: 10.1002/ppul.21231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Chronic thromboembolic pulmonary hypertension (CTEPH) occurs in patients with recurrent or chronic pulmonary embolism, and is a rare but potentially devastating disease in adolescents and young adults. Pulmonary thromboendarterectomy (PTE) is an important curative therapy for patients with CTEPH. The importance of this treatment may be under-appreciated and under-utilized in adolescents and young adults. STUDY DESIGN We performed a chart review of all patients <24 years of age who had PTE performed for CTEPH at our institution from 2003-2009 (seven patients, average age 20.2 +/- 2.5 years, range 17-23 years, average BMI 34 +/- 12 kg/m(2)). All patients had their operations performed by a single surgeon. RESULTS There were no deaths. Three of the seven patients were incorrectly diagnosed prior to the diagnosis of CTEPH. Right ventricular systolic pressure decreased from 61.3 +/- 19 mmHg pre-operatively to 31.8 +/- 5 mmHg post-operatively (P = 0.008). All patients reported symptomatic relief, and no patient has had recurrence of CTEPH. CONCLUSION Although rare in the young patient, recurrent pulmonary emboli can have devastating consequences. The potentially lethal implications of CTEPH may be under-appreciated in adolescents and young adults. When indicated, PTE is a definitive, curative procedure with low morbidity and mortality.
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Affiliation(s)
- Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Alomari AI, Burrows PE, Lee EY, Hedequist DJ, Mulliken JB, Fishman SJ. CLOVES syndrome with thoracic and central phlebectasia: increased risk of pulmonary embolism. J Thorac Cardiovasc Surg 2010; 140:459-63. [PMID: 20537357 DOI: 10.1016/j.jtcvs.2010.04.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Revised: 04/07/2010] [Accepted: 04/25/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVE CLOVES syndrome (congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal/scoliosis and spinal abnormalities) is a rare, complex overgrowth syndrome with serious morbidity. In this communication we studied the presence of central and thoracic phlebectasia in patients with CLOVES syndrome and its clinical implications. METHODS We conducted a comprehensive search of our databases at Children's Hospital Boston over the last 10 years (1999-2008) for patients with CLOVES syndrome and central and thoracic phlebectasia. Medical records, clinical photographs, and imaging studies of varying modalities were reviewed. RESULTS Review of the clinical data and imaging studies of 12 patients with CLOVES syndrome documented the presence of central and thoracic phlebectasia in 11 patients. Two patients had serious perioperative pulmonary embolism, and 1 died. CONCLUSIONS Central and thoracic phlebectasia in patients with CLOVES syndrome is common and increases the risk of pulmonary embolism. Aggressive prophylactic measures should be considered before major interventions.
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Affiliation(s)
- Ahmad I Alomari
- Division of Vascular and Interventional Radiology, Children's Hospital Boston and Harvard Medical School, Boston, Mass 02115, USA.
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Johnson JN, Driscoll DJ, McGregor CGA. Pulmonary thromboendarterectomy in Klippel-Trénaunay syndrome. J Thorac Cardiovasc Surg 2010; 140:e41-3. [PMID: 20434178 DOI: 10.1016/j.jtcvs.2010.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 03/20/2010] [Indexed: 11/29/2022]
Affiliation(s)
- Jonathan N Johnson
- Department of Pediatrics, Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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Samimi M, Lorette G. Syndrome de Klippel-Trenaunay. Presse Med 2010; 39:487-94. [DOI: 10.1016/j.lpm.2009.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Revised: 09/13/2009] [Accepted: 10/14/2009] [Indexed: 01/19/2023] Open
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Herman J, Musil D. Klippel-Trénaunay syndrome associated with great saphenous vein aplasia. Phlebology 2010; 25:35-7. [PMID: 20118344 DOI: 10.1258/phleb.2009.008079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Klippel-Trénaunay syndrome (KTS) is a rare, sporadic, congenital vascular disease of unknown aetiology. KTS could be associated with infliction of other regions. An association with great saphenous vein aplasia has never been described.
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Affiliation(s)
- J Herman
- 2nd Dept. of Surgery, Teaching Hospital-Medical Faculty, Palacký University, I.P. Pavlova 6, 775 20 Olomouc, Czech Republic.
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Dompmartin A, Ballieux F, Thibon P, Lequerrec A, Hermans C, Clapuyt P, Barrellier MT, Hammer F, Labbé D, Vikkula M, Boon LM. Elevated D-dimer level in the differential diagnosis of venous malformations. ARCHIVES OF DERMATOLOGY 2009; 145:1239-44. [PMID: 19917952 PMCID: PMC5561655 DOI: 10.1001/archdermatol.2009.296] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate if elevated D-dimer level is specific for venous malformations (VMs) and thus useful for differential diagnosis, which can be problematic even in specialized interdisciplinary centers. Localized intravascular coagulopathy, characterized by elevated D-dimer levels, has been observed in approximately 40% of patients with VMs. DESIGN Prospective convenience sample accrued from 2 interdisciplinary sites. SETTING Two interdisciplinary centers for vascular anomalies in Brussels, Belgium, and Caen, France PARTICIPANTS The study population comprised 280 patients with clinical data, Doppler ultrasonograms (for 251 patients), and coagulation parameter measurements. Main Outcome Measure Measurement of D-dimer levels. RESULTS A VM was diagnosed in 195 of 280 patients (69.6%), and 83 of them had elevated D-dimer levels; the sensitivity of D-dimer dosage was 42.6% (95% confidence interval, 35.6%-49.5%). Among the 85 patients without VM, D-dimer levels were elevated only in 3 patients; the specificity of the dosage was 96.5% (95% confidence interval, 92.5%-100%). CONCLUSIONS Elevated D-dimer level is highly specific for VMs (pure, combined, or syndromic), and therefore this easy and inexpensive biomarker test should become part of the clinical evaluation of vascular anomalies. It can detect hidden VMs and help differentiate glomuvenous malformation (normal D-dimer levels) from other multifocal venous lesions. Elevated D-dimer level also differentiates a VM from a lymphatic malformation. Moreover, slow-flow Klippel-Trenaunay syndrome (capillaro-lymphatico-venous malformation with limb hypertrophy) can be distinguished from fast-flow Parkes Weber syndrome (capillary malformation with underlying multiple microfistulas and limb hypertrophy). For these reasons, D-dimer level measurement is a useful complementary tool for diagnosing vascular anomalies in everyday practice.
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Affiliation(s)
- Anne Dompmartin
- Department of Dermatology, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Fanny Ballieux
- Center for Vascular Anomalies, Division of Plastic Surgery, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Pascal Thibon
- Department of Hygiene, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Agnès Lequerrec
- Department of Hematology, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Cédric Hermans
- Hematosis and Thrombosis Unit, Division of Haematology & Laboratory of Thrombosis and Haemostasis, Division of Biological Chemistry, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Philippe Clapuyt
- Department of Radiology, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Marie-Thérèse Barrellier
- Department of Dermatology, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Franck Hammer
- Department of Radiology, Université catholique de Louvain, Cliniques universitaires St Luc
| | - Daniel Labbé
- Department of Plastic Surgery, Université de Caen Basse Normandie, CHU Caen, Av Georges Clémenceau, 14033 Caen, France
| | - Miikka Vikkula
- Laboratory of Human Molecular Genetics, Université catholique de Louvain, de Duve Institute, B-1200 Brussels, Belgium
| | - Laurence M Boon
- Center for Vascular Anomalies, Division of Plastic Surgery, Université catholique de Louvain, Cliniques universitaires St Luc
- Laboratory of Human Molecular Genetics, Université catholique de Louvain, de Duve Institute, B-1200 Brussels, Belgium
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Fakir E, Roberts T, Stephen L, Beighton P. Klippel-Trenaunay-Weber syndrome: orodental manifestations and management considerations. ACTA ACUST UNITED AC 2009; 107:754-8. [PMID: 19464652 DOI: 10.1016/j.tripleo.2009.01.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 12/22/2008] [Accepted: 01/15/2009] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Ebrahim Fakir
- Faculty of Dentistry, University of the Western Cape, Cape Town, South Africa
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Jensen L, Heath KJ, Scott G, Byard RW. Sudden death and the forensic evaluation of neurocutaneous syndromes. J Forensic Leg Med 2009; 16:369-74. [DOI: 10.1016/j.jflm.2009.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Accepted: 04/02/2009] [Indexed: 01/19/2023]
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