Early experience of thalidomide therapy for high-grade peripheral and facial arteriovenous malformations

BACKGROUND

Arteriovenous malformations (AVMs) are developmental defects in the vascular system with abnormal connections between arteries and veins. A minority of AVMs are characterized by aggressive growth and continue to proliferate despite maximal surgical and interventional therapy. We report our outcomes with the use of thalidomide as the only UK specialist center adopting this novel approach for the management of AVMs refractory to conventional therapy.

METHODS

This was a retrospective case series which included only complex and proliferative AVM lesions (Schobinger grade III and IV). All patients prescribed thalidomide on a compassionate basis between September 2006 and August 2022 after attempts at embolosclerotherapy without satisfactory response were reviewed.

RESULTS

Eleven patients were included in our study. The median total duration of thalidomide use was 10 months. Two thirds of patients with pain (six of nine) reported an improvement, three quarters reported a reduction in swelling (six of eight) and all who presented with bleeding reported improvement in overall volume or frequency (four of four). Over the study period, 45% achieved a non-proliferative state with no further target vessel demonstrable on angiography. Mild, tolerable side effects such as fatigue were common (73%). There was only one major adverse reaction (neutropenia) necessitating cessation of therapy.

CONCLUSIONS

We can conclude that thalidomide is able to reduce the symptom burden for patients with complex and proliferative AVMs that were refractory to established treatment modalities. Adverse effects are common, but the benefit achieved from taking thalidomide in otherwise treatment resistant cases outweighs the risks, most of which are manageable.

Histopathological analysis of vascular malformations

OBJECTIVE

To propose and develop a histopathological criteria to help diagnose vascular malformations.

METHODS

All patients who underwent surgical resection and had a confirmed histopathological diagnosis of vascular malformations from 01 March 2018-26 February 2020 were included. A criteria based on 10 parameters was developed to help diagnose vascular malformations. Discrepancies between clinical and histopathological diagnosis were evaluated.

RESULTS

A total of 18 cases were identified. There was a discrepancy between the clinical diagnosis and the initially reported histopathological diagnosis in 16 cases (88.9%). This was reduced to 7 (38.9%) and 6 cases (33.3%) with first and second time revised histopathological analysis using proposed criteria.

CONCLUSIONS

The discrepancy between clinical and histopathological diagnoses of vascular malformations has highlighted the requirement of an agreed criteria for histopathologists to help formulate their diagnosis. The proposed criteria may be used as a guide in addressing this and guide treatment and improve clinical practice.

Efficacy and safety of embolo-sclerotherapy of arteriovenous malformations with foam sodium tetradecyl sulphate

BACKGROUND

To evaluate the efficacy and safety of embolo-sclerotherapy (EST) particularly with foamed sclerotherapy in the treatment of arteriovenous malformations (AVMs).

METHODS

All patients with AVM who underwent interventional therapy i.e. EST from January 1^st, 2015 - December 31^st, 2019 were identified through a prospective database. Types of AVM were classified according to Schobinger's classification. The outcome measures assessed efficacy and complications. The former was divided into four groups: no response, mild response, moderate response, and complete response.. Complications were defined as any tissue or functional damage, distal embolization or tissue reaction. Continuous variables were compared using analysis of variance (ANOVA) F test and discrete variables were analysed using χ² tests. P<0.05 was considered significant.

RESULTS

A total of 65 patients were included. There was no statistical difference amongst the volume of foam STS 3% or alcohol used across all types of AVM. Overall, majority of patients (86.2%) reported some degree of improvement following interventional therapy. Six (9.2%) patients experienced complications including necrosis and amputation. The proportions of complication were significantly different across the categories (P=0.009). Patients with type III AVM seemed to report more complications than others.

CONCLUSIONS

Foam sclerotherapy was clinically effective and safe for patients with AVM. This study showed that foam sclerotherapy with STS 3% provided a safe and efficacious alternative sclerosant to ethanol despite it was not often reported to be used to treat AVM. However, a combination of embolic agents is likely required to treat type IV AVMs.

Extreme eutrophication and salinisation in the Coorong estuarine-lagoon ecosystem of Australia's largest river basin (Murray-Darling)

Estuaries in rainfall poor regions are highly susceptible to climatic and hydrological changes. The Coorong, a Ramsar-listed estuarine-coastal lagoon at the end of the Murray-Darling Basin (Australia), has experienced declining ecological health over recent decades. Twenty years of environmental data were analysed to assess patterns and drivers of water quality changes. Large areas of the Coorong are now persistently hyper-saline (salinity >80 psu) and hypereutrophic (total nitrogen, TN > 4 mg L^-1, total phosphorus, TP > 0.2 mg L^-1, chlorophyll a > 50 μg L^-1) which coincided with reduced flushing due to diminished freshwater inflows and increasing evapo-concentration. Sediment quality also was related to flushing, with higher concentrations of organic carbon, TN, TP and sulfides as salinity increased. While total nutrient levels are very high, dissolved inorganic nutrients are generally low. Increased lagoonal flushing would be beneficial to reduce the hypersalinisation and hypereutrophication and improve ecosystem health.

Efficacy and safety of foam sclerotherapy with sodium tetradecyl sulfate as preferred sclerosant of venous malformations based on experience from a single specialist center

OBJECTIVE

We have assessed the efficacy and safety of interventional therapy for venous malformations (VMs), with foam sclerotherapy as the treatment of choice according to our experience at a single specialist center.

METHODS

All the patients with VMs who had undergone interventional therapy (ie, embolo-sclerotherapy and/or open surgery) from January 1, 2015 to December 31, 2019 were identified through a prospective database. The VM types were classified according to the Puig classification. The outcome measures assessed included the efficacy and complications. The former was divided into four groups: no response, mild response, moderate response, and complete response. The complications were defined as any tissue or functional damage, distal embolization, or tissue reaction. The continuous variables were compared using the analysis of variance F test, and discrete variables were analyzed using the χ² tests. P values < .05 were considered statistically significant.

RESULTS

A total of 207 patients were included. Puig type I lesions were significantly less likely to have received foam sclerotherapy using sodium tetradecyl sulfate (STS) 3% (P ≤ .001) and more likely to have been surgically excised (P ≤ .001). At the patient's first procedure during the study period, the volumes of foam STS 3% were significantly different across all types of VM (P ≤ .001). The patients with type I VMs had received a lower volume of STS 3% compared with those with type II and III VMs. The efficacy outcome categories were significantly different across all types of VMs (P ≤ .001). Overall, only 14 patients (6.8%) had reported no improvement in efficacy, and 38 patients (18%) had not attended follow-up. Therefore, 154 patients (74.8%) had experienced some form of efficacious outcome. Ten patients (4.8%) had developed complications such as hematoma, thrombophlebitis, and ulceration. The incidence of complications differed significantly across the categories (P = .030), with more complications reported for those with type I VMs.

CONCLUSIONS

We found that intervention with foam sclerotherapy using STS 3% is clinically effective and safe for patients with VMs and was most successful for those with Puig type I and II VMs.

Early follow-up quality of life and mental health of patients with congenital vascular malformations cared for in a multi-disciplinary specialist centre

OBJECTIVE

The study aimed to evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) from a variety of treatment options.

METHODS

All patients with CVM who received care and had follow-up between February 1st 2018 and January 31st 2020 were included. The health-related QoL, pain, and mental health were assessed with RAND Health Care 36-Item Short Form Survey (SF-36), visual analogue score for pain (VAS-P) and Hospital Anxiety and Depression Scale (HADS). Paired t-test was used for all analyses. p < .05 were considered significant.

RESULTS

In total, 110 patients with a mean age of 36.9 years were included in this study. In all patients following care, significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both p = .01). This was largely driven by high-flow vascular malformation patients who responded better to embolo-sclerotherapy, which revealed significant improvement in the bodily pain domain of SF-36 (p = .002) and VAS-P (p = .02). Patients who received supportive treatment only reported significant improvement in mental health (p = .004) and social functioning (p = .03) domains of SF-36. Meanwhile, patients treated with embolo-sclerotherapy reported significant improvement only in VAS-P (p = .02).

CONCLUSIONS

This study concluded that the effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research should therefore, include larger sample size and longer term follow-up to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

The trend of percutaneous and open surgical procedures for peripheral arteriovenous malformations in the National Health Service England

INTRODUCTION

This study aimed to assess the trend of percutaneous and open surgical procedures for peripheral arteriovenous malformations (AVMs) performed in NHS hospitals in England between 2012 and 2018.

METHODS

Hospital Episode Statistics (HES) is a freely available data warehouse that represents the whole population of England served by the NHS. Data from the HES database was obtained and analysed for all hospital episodes between 2012 and 2018 for the total number and trend of 'primary diagnosis', and 'primary procedures and interventions' identified for peripheral AVMs.

RESULTS

Over the period studied, there was an increase in the total number of admissions for peripheral AVMs; total primary diagnosis increased from 2242 to 2857 per year. Open surgery remained more commonly performed than percutaneous procedures throughout the studied period. However, the overall percentage of primary procedures and interventions being percutaneous in this period increased from 29.8% to 41.0% per year. The increase in the number of percutaneous procedures per year seemed to occur in both children (from 43 to 124) and adults (from 408 to 492) over the course of the study period.

CONCLUSIONS

This study concluded that open surgery remained the most commonly performed primary procedure for peripheral AVMs, although there was an increasing trend for percutaneous procedures in NHS hospitals in England. The increase in the number and percentage of percutaneous procedures for peripheral AVMs was likely to have significant resource implications for the provision of care for patients with peripheral AVMs in NHS hospitals.

522 Early Follow-Up Quality of Life and Mental Health of Patients with Congenital Vascular Malformations Cared for in a Multi-Disciplinary Specialist Center

Aim

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist center

Method

This was a prospective observational study. All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between February 1st 2018 and January 31st 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. P&lt;0.05 were considered significant.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolo-sclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusions

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

518 Efficacy and Safety of Embolo-Sclerotherapy of Low-Flow Vascular Malformations Based on the Experience from a Single Specialist Centre

Aim

To evaluate the efficacy and safety of embolo-sclerotherapy (EST) of low-flow vascular malformations (LFVM) in a specialist vascular anomalies centre.

Method

All patients with LFVM who underwent EST from 01 January 2015–31 December 2019 were retrospectively reviewed. All ESTs were performed with foam STS 3%, ethanol, coils and/or other substances e.g., triamcinolone. LFVMs were grouped according to Puig's classification. The outcome measures were treatment effects and complications. Continuous variables were compared using analysis of variance (ANOVA) F test. Other discrete variables were compared using Chi-squared tests. P&lt;0.05 were considered significant.

Results

A total of 207 patients, with a mean age of 32 years (range 1–71 years) were included. The use of EST with foam STS was significantly lower for type I LFVM (61.8%) compared to others (p&lt;0.001). However, significantly higher type I LFVM (26.5%) were treated with surgery than EST (p&lt;0.001). Overall, outcome categories were significantly different across all types of LFVM (p&lt;0.001), with more discharges for Type I (52.9%) LFVMs but more failure to follow-up in patients with Type II (24.5%) LFVM. EST complications was significantly higher with type I (14.7%) LFVMs (p=0.030). The doses of STS in the first procedure were significantly different across all types of LFVM (p&lt;0.001) with most type I LFVM patients receiving ≤2ml.

Conclusions

EST particularly with foam sclerotherapy is clinically effective and safe for patients with LFVM especially in those with Puig's type I and II lesions. This classification may provide an important guide to volume of sclerosant required and the potential success rate.

O064 Early follow-up quality of life and mental health of patients with congenital vascular malformations cared for in a multi-disciplinary specialist center

Introduction

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist centre

Methods

All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between 1 February 2018 and 31 January 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. Differences were considered significant at P&lt;0.05.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolosclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusion

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Take-home message

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Abstract P168: Promising Diagnostic Biomarkers For Congenital Vascular Malformations

Background: Congenital vascular malformations (CVMs) are vascular lesions that result from developmental errors during embryogenesis. They can occur anywhere in the body, causing pain, bleeding, ulcers, disfiguration, organ failure or limb loss. Depending on intralesional blood flow dynamics, CVMs can be broadly classified into low-flow (LF), which involve veins, lymphatics, capillaries or a mixture, and high-flow (HF), which involve arteries and veins. Accurate diagnosis and monitoring of LF and HF CVMs remains challenging and requires a wide range of imaging modalities.

Aim: We sought to identify potential diagnostic serum biomarkers, particularly those pertaining to the processes of inflammation and angiogenesis.

Methods: Sera were isolated from the peripheral bloods of consented healthy controls ( n = 10) and patients diagnosed as having either LF ( n = 10) or HF ( n = 10) CVMs. Various mediators of inflammation and angiogenesis were analysed in the sera using the Inflammation 20-Plex and Angiogenesis 18-Plex Human ProcartaPlex™ Panels. The levels of these mediators in patients with LF or HF CVMs were compared with those in healthy controls using the Kruskall-Wallis test and correlated with lesion volumes and visual analogue scores for pain using the Spearman rank correlation test.

Results: Compared to healthy controls, the inflammatory mediators E-selectin, IFNα, IFNγ, IL1β, IL4, IL12, IL17, MIP1α, MIP1β and TNFα were elevated in the sera of LF CVM patients, whereas only MIP1α was raised in the sera of HF CVM patients. None of the angiogenic mediators were altered in the sera of patients with LF or HF CVMs. Serum IFNα, IFNγ, IL4, IL12, TNFα, VEGFA, VEGFD and syndecan correlated positively with pain scores in patients with LF CVMs, whereas only IP10 did in patients with HF CVMs. Serum Ang1 and leptin correlated negatively with lesion volumes in patients with LF or HF CVMs, respectively.

Conclusion: Serum inflammatory mediators could be used as biomarkers to distinguish LF from HF CVMs and their expression seemed to be associated with pain severity in patients with LF CVMs. The angiogenic mediators Ang1 and leptin were associated with lesion volumes in patients with LF or HF CVMs, respectively.

Incidence of major complications from embolo-sclerotherapy of head and neck vascular malformations in a single specialist centre

OBJECTIVE

Current data on the nature and rate of major complications for embolo-sclerotherapy (EST) of vascular malformations are scarce. However, even fewer studies focus on vascular malformations specific to the head and neck, which confer an increased specific risk of airway compromise, neurologic and ophthalmologic injury. More understanding is required surrounding the type and incidence of complications to improve treatment planning and informed consent. Therefore, this study aimed to review major complications secondary to EST of head and neck vascular malformations over a 5-year period in a single specialized multidisciplinary centre for vascular anomalies.

METHODS

All interventions were decided by the multidisciplinary team. Demographic, procedural and complication data between 1st January 2013 and 31st December 2017 were prospectively documented in a dedicated database and analysed. EST of high-flow vascular malformations (HFVMs) was performed by selective catheter angiography or direct injection, and by direct injection only for low-flow vascular malformations (LFVMs). Major complications were defined as any tissue or functional damage caused by direct injection, distal embolization or tissue reaction and were decided by the multidisciplinary team.

RESULTS

Forty-eight patients (median age of 35 years; range of 14-70 years; 18 men and 30 women) had 100 EST procedures for head and neck vascular malformation. Of these, 14 patients had EST for HFVM and 34 patients for LFVM, total 43 and 57 procedures, respectively. Overall, five patients with HFVM developed major complications from EST when compared with two patients with LFVM (p = 0.0167). Two patients required pre-emptive tracheostomy due to risk of post-operative airway compromise. Overall, seven (14.6%) patients experienced major complication from EST. In the HFVM group, major complications from EST occurred in five patients; four cases of tissue ulceration and necrosis (two needed debridement, one healed with resultant fibrosis that impeded speech and one resolved spontaneously) and one post-procedural airway compromise requiring tracheostomy. Meanwhile, in the LFVM group, major complications occurred in two patients; one case of severe necrosis involving the alar cartilage, lip and cheek requiring debridement and reconstruction under plastics and one simple cellulitis. No patients sustained stroke or vision impairment.

CONCLUSIONS

EST is relatively safe for head and neck vascular malformations in a high-volume experienced centre. Our major complication rate of 14.6% per patient (35.7% for HFVM; 5.9% for LFVM) or 7% per procedure (11.6% for HFVM; 3.5% LFVM) compares favourably with published data from other centres. These data will improve treatment planning and informed consent for EST for both HFVM and LFVM of the head and neck.

Giant parapharyngeal high-flow arteriovenous malformation causing airway compromise: emergency embolo-sclerotherapy via an endovascular-only approach

Head and neck arteriovenous malformations are the commonest extracranial vascular malformations but demonstrate a unique challenge in the limited available surgical options secondary to their intimate association to vital structures. We present a case of middle-aged female patient who presented with threatened upper-airway obstruction and bleeding secondary to a slowly enlarging parapharyngeal arteriovenous malformations. She was treated with an endovascular-only approach with the proximal arteriole branches selectively undergoing embolo-sclerotherapy with an optimal radiological and clinical outcome. We also demonstrate the utility of elective tracheostomy prior to intervention.

O75: SINGLE CENTRE EXPERIENCE OF SIROLIMUS THERAPY IN HEAD AND NECK VASCULAR MALFORMATIONS

Introduction

To assess the efficacy and safety of Sirolimus in the treatment of low-flow head and neck (H&N) vascular malformations

Method

Patients who presented to our tertiary referral clinic were assessed for eligibility. Suitable patients were commenced on Sirolimus at 0.8 mg/m2, administered orally twice daily, which was approved by our trust Drug and Therapeutic Committee. Patients were reviewed on a monthly basis for a total of six months with an additional one-month review to check for effects upon ceasing treatment. Efficacy and safety were measured through functional and radiological response, laboratory investigations and quality of life questionnaire (36-Item Short Form Health Survey (SF-36), Hospital Anxiety and Depression Scale (HADS) and Visual Analogue Score for Pain (VAS-P)).

Result

Seven patients (mean age 39 years, range 23-65 years) were recruited. One patient did not complete treatment due to intolerable side effects. All patients had a partial response with no patients showing disease progression or complete response. All post-treatment MRI scans showed stable disease with five patients demonstrating a decrease in lesion volume. Five patients reported return of symptoms at one-month post review upon discontinuation of treatment. No statistical significance (P&gt;0.05) in all eight domains of SF-36, HADS, VAS-P and radiological vascular lesion volume between pre- and post-treatment. Most common reported side effects were mouth ulcers (n=2) and metabolic/laboratory abnormality (n=2)

Conclusion

Sirolimus is an effective and safe treatment for patients with complicated low-flow H&N vascular malformations. This provides an alternative treatment where interventional therapy is considered to be limited or challenging.

Take-home message

Sirolimus is an effective and safe treatment option for patients with complicated low-flow head and neck vascular malformations where interventional therapy is limited or challenging.

Single Center Experience of Sirolimus Therapy in Head and Neck Low-flow Vascular Malformations

OBJECTIVE

Recently, studies have shown that sirolimus is clinically efficacious in the treatment of some low-flow vascular malformations (LFVM). This study aimed to assess the efficacy and safety of sirolimus in treating complex head and neck (H&N) LFVM that were challenging and/or refractory to standard treatment.

METHODS

Each patient had baseline and 6-months assessments consisting of clinical history and examination, quality of life (QoL) questionnaires, laboratory investigations, MRI and medical photography. Patients were followed up 1-week and then 1-monthly for 6-months. Wilcoxon signed-rank test was used to compare pre-and 6-months treatment in all 8 domains of RAND 36-Item Short Form Health Survey (SF-36), hospital anxiety and depression scale (HADS), and visual analog score for pain (VAS-P). P < 0.05 was considered significant.

RESULTS

Seven patients (median age 43 years, range 23-65 years) were recruited. Six patients completed the six-months course of therapy with 1 patient withdrawing due to intolerable side effects. All six patients reported reduction of swelling with and without other symptom improvement related to the vascular malformations while on treatment. However, at 1-month review after discontinuation of sirolimus, 5 patients reported return of initial symptoms. Overall, patients demonstrated an improvement in QoL six-months treatment but there was no statistical significance (P > 0.05) in all 8 domains of SF-36, HADS and VAS-P. Five patients demonstrated a minimum 10% decrease in lesion size six-months treatment (median 21%, range 13-40%). A Wilcoxon signed-rank test showed that sirolimus treatment did elicit a statistically significant change in lesion size in either direction (Z = -1.992, P = 0.046). The most common side effects found were dyslipidaemia (n-4) and mouth ulcers (n = 2).

CONCLUSION

In our preliminary experience, sirolimus is effective and safe in treating patients with complex H&N LFVM. This provides an alternative treatment where standard treatment is challenging and/or refractory.

Quality of life and mental health of patients with vascular malformations in a single specialist center in the United Kingdom

OBJECTIVE

Patients with vascular malformations suffer from chronic debilitating symptoms that have been shown to contribute negatively to their quality of life (QoL) and mental health. Despite this, the current literature evaluating the QoL and mental health of patients with vascular malformations remains scarce. Our aim was to evaluate the QoL and mental health of patients with vascular malformations.

METHODS

We prospectively analyzed the validated health-related QoL (HRQoL) questionnaires: the RAND Health Care 36-Item Short Form Survey (SF-36), Hospital Anxiety and Depression Scale (HADS), and visual analogue score for pain reported by 253 patients with vascular malformations in a specialist center of vascular anomalies in the UK over two years.

RESULTS

Patients with vascular malformations reported significantly poorer SF-36 scores in all domains compared with the UK general population. Patients with low-flow vascular malformations and arteriovenous malformations reported little variations in SF-36, HADS, and visual analogue score for pain scores. No significant association was found between age and any of the health-related QoL scores, other than the physical functioning in SF-36. Female patients reported significantly lower physical and social functioning of SF-36 and worse HADS-Depression than their male counterparts. Patients with syndromic vascular malformations reported significantly lower SF-36 scores in role-physical, role-emotional and bodily pain than nonsyndromic vascular malformations.

CONCLUSIONS

This study concluded that patients with vascular malformations reported worse QoL than the UK general population. Therefore, the assessment and management of QoL and mental health should be incorporated into the overall treatment strategies of patients with vascular malformations.

Illuminating the nidus: The role of FDG PET/CT in high flow arteriovenous vascular malformations

The appropriate identification and localization of a nidus of a high flow arteriovenous malformation is crucial to guide targeted interventional therapy. However, the nidus of a complex or previously treated HFAVM can be difficult to non-invasively demonstrate on magnetic resonance imaging alone. We describe a unique case of a 56-year-old female with a complex high flow arteriovenous malformation in which we demonstrated the feasibility of fluorodeoxyglucose positron emission tomography/computed tomography to non-invasively delineate the nidus which subsequently guided successful targeted interventional therapy.

Patient radiation exposure from embolo-sclerotherapy of peripheral vascular malformations

OBJECTIVE

Embolo-sclerotherapy (EST) is the mainstay therapy for peripheral vascular malformations that involves the exposure of patients to ionizing radiation. We analyzed the radiation exposure to patients from EST of peripheral vascular malformations during a 5-year period in a single specialist center.

METHODS

All patients who had undergone EST at a single specialist center for peripheral vascular malformations from January 1, 2013 to January 8, 2018 were identified from a prospectively collected database. Data collection included basic demographics, procedure date, anatomic site, type of vascular malformations, and procedural details. Radiation exposure, measured as the dose-area product (DAP) and fluoroscopy time, of all patients who had undergone EST during the study period were retrospectively reviewed. Statistical analysis was performed using the Mann-Whitney U and Kruskal-Wallis tests for comparison between subgroups. P < .05 was considered statistically significant.

RESULTS

A total of 237 patients (median age, 30 years; range, 1-73 years) had undergone 419 EST sessions during the study period. Of the 237 patients, 61 (25.7%) had had arteriovenous malformations (AVMs) and had undergone 140 EST sessions (33.4%) and 176 (74.3%) had had venous and lymphatic malformations and had undergone 279 EST sessions (66.6%). Patients with AVMs had undergone a median of 2 procedures (range, 1-13) compared with a median of 1 (range, 1-6) for venous and lymphatic malformations within the study period. The median DAP for the single and cumulative EST for peripheral vascular malformations was 1.26 Gycm² (range, 0.00-698.36 Gycm²) and 1.91 Gycm² (range, 0.00-1300.24 Gycm²), respectively. The median fluoroscopy time for single and cumulative EST was 19 seconds (range, 1-3846 seconds) and 30 seconds (range, 1-5843 seconds), respectively. Significantly greater patient radiation exposure, in DAP and fluoroscopy time, was measured for single and cumulative EST for AVMs compared with venous and lymphatic malformations (P < .01 for both; Mann-Whitney U test). A significant difference in DAP but not fluoroscopy time was found when the anatomic areas of vascular malformations were compared.

CONCLUSIONS

Patient radiation exposure for EST for peripheral vascular malformations, measured in DAP and fluoroscopy time, appeared to be generally less than that reported for endovascular arterial and deep venous interventions. However, some patients with peripheral vascular malformations received relatively high radiation doses. Further studies to investigate the risk factors and long-term side effects of radiation exposure in these patients and strategies to reduce these are required.

Novel use of arterial spin labelling in the imaging of peripheral vascular malformations

We present a novel use of arterial spin labelling (ASL), a MRI perfusion technique, to assess a high-flow, peripheral vascular malformation (PVM), specifically a large arteriovenous malformation in the left forearm of a 20-year-old female. While there has been experience with ASL in the assessment of intracranial vascular malformations, there has been no known use of ASL in the evaluation of PVMs. We also discuss the potential benefits and limitations of ASL in the imaging of PVMs. The promising results from this case warrant further research on ASL in the investigation of PVMs.

Incidence of major complication following embolo-sclerotherapy for upper and lower extremity vascular malformations

OBJECTIVE

The current literature on the major complications of embolo-sclerotherapy of upper and lower extremity vascular malformations is scarce. Evaluating and understanding the rates and types of potential major complications of embolo-sclerotherapy of vascular malformations help treatment planning and informed consent. Therefore, this study reviewed major complications following embolo-sclerotherapy of all upper and lower extremity vascular malformations in a single specialized multidisciplinary vascular malformation center over a 5-year period.

METHODS

All patients with vascular malformations underwent multidisciplinary directed intervention. Demographic, procedural, follow-up, and complication data were collected prospectively in a dedicated database, and reviewed retrospectively. Major complications for upper and lower extremity vascular malformations from 1 January 2013 to 31 December 2017 were analyzed. All embolo-sclerotherapies of high-flow vascular malformations (HFVMs) were performed under selective catheter angiography and direct injection, but low-flow vascular malformations (LFVM) with direct injection only. Major complications were defined as any tissue or functional damage caused by direct injection, distal embolization, or tissue reaction.

RESULTS

Seventy patients (median age of 25 years; 44 males and 26 females) had 150 embolo-sclerotherapy procedures for upper extremity vascular malformation. Of these, 28 patients had embolo-sclerotherapy for HFVM and 42 patients for LFVM; total 78 and 72 procedures, respectively. A total of 107 patients (median age of 26 years; 42 males and 65 females) had 160 embolo-sclerotherapy interventions for lower extremity vascular malformations. Of these, 18 patients had embolo-sclerotherapy for HFVM and 89 patients for LFVM; total of 30 and 130 procedures, respectively. The overall major complication rates following embolo-sclerotherapy of upper and lower extremity vascular malformations were 14.3% and 4.7%, respectively (P = 0.030). In the upper extremity HFVM group, major complications from embolo-sclerotherapy occurred in five patients; three ischemic fingers requiring amputation and two skin ulcerations. Meanwhile, in the upper extremity LFVM group, major complications occurred in five patients; one median nerve injury requiring nerve grafting and hand therapy, one hand contracture requiring tendon release, and three skin ulcerations. There was only one major complication, which was cellulitis in the lower extremity HFVM group. In the lower extremity LFVM group, major complications occurred in four patients; two skin ulcerations, one cellulitis, and one deep vein thrombosis.

CONCLUSIONS

Embolo-sclerotherapy is relatively safe for upper and lower extremity vascular malformations in a high-volume experienced center where our major complication rates were 14.3% and 4.7%, respectively, which compare favorably or similar to those reported in most recent literature. These outcomes will direct treatment strategies to avoid local and systemic toxic complications in the upper and lower extremity, for both HFVM and LFVM, and to improve informed consent.

Emerging importance of molecular pathogenesis of vascular malformations in clinical practice and classifications

Vascular malformations occur during early vascular development resulting in abnormally formed vessels that can manifest as arterial, venous, capillary or lymphatic lesions, or in combination, and include local tissue overdevelopment. Vascular malformations are largely caused by sporadic somatic gene mutations. This article aims to review and discuss current molecular signaling pathways and therapeutic targets for vascular malformations and to classify vascular malformations according to the molecular pathways involved. A literature review was performed using Embase and Medline. Different MeSH terms were combined for the search strategy, with the aim of encompassing all studies describing the classification, pathogenesis, and treatment of vascular malformations. Major pathways involved in the pathogenesis of vascular malformations are vascular endothelial growth factor (VEGF), Ras/Raf/MEK/ERK, angiopoietin-TIE2, transforming growth factor beta (TGF-β), and PI3K/AKT/mTOR. These pathways are involved in controlling cellular growth, apoptosis, differentiation, and proliferation, and play a central role in endothelial cell signaling and angiogenesis. Many vascular malformations share similar aberrant molecular signaling pathways with cancers and inflammatory disorders. Therefore, selective anticancer agents and immunosuppressants may be beneficial in treating vascular malformations of specific mutations. The current classification systems of vascular malformations, including the International Society of the Study of Vascular Anomalies (ISSVA) classification, are primarily observational and clinical, and are not based on the molecular pathways involved in the pathogenesis of the condition. Several molecular pathways with potential therapeutic targets have been demonstrated to contribute to the development of various vascular anomalies. Classifying vascular malformations based on their molecular pathogenesis may improve treatment by determining the underlying nature of the condition and their potential therapeutic target.

Ten-year single-centre experience with type II endoleaks: Intervention versus observation

Our objective was to determine the relative merits of intervention or observation of type II endoleaks (T2Ls). A retrospective analysis was performed on 386 infra-renal endovascular aneurysm repair (IR-EVAR) patients from 2006 to 2015. Annual surveillance imaging of patients undergoing EVAR at our centre were analysed, and all endoleaks were subjected to a multidisciplinary team meeting for consideration and treatment. In the 10-year time frame, 386 patients (79.5±8.7 years) underwent an IR-EVAR. Eighty-one patients (21.0%) developed a T2L and intervention was undertaken in 28 (34.6%): 17 (60.7%) were treated via a transarterial approach (TA) and 11 (39.3%) using the translumbar approach (TL). Fifty-three patients (65.4%) with T2Ls were managed conservatively. Patients who received T2L treatment had a greater proportion of recurrent T2Ls than patients who were conservatively managed ( p=0.032). T2Ls associated with aneurysmal growth were more resistant to treatment than those where there was no change or a decrease in aneurysm size during follow-up (0.033). There was no significant difference in the TA and TL approach with respect to endoleak repair success ( p=0.525). Treatment of a T2L did not confer a survival advantage compared to conservative management ( p=0.449) nor did the choice of either the TA or TL approach ( p=0.148). Our study suggests the development of a T2L associated with aneurysm growth may represent an aggressive phenotype that is resistant to treatment. However, this did not lead to an increased risk of mortality over follow-up. Neither a transarterial nor a translumbar approach to treating a T2L conferred superiority.

Spontaneous sphenopalatine pseudoaneurysm: recurrent epistaxis in a patient with cryptogenic vasculopathy

We present a unique case of recurrent epistaxis secondary to a spontaneous sphenopalatine artery aneurysm in a young woman. This was investigated with an external carotid artery angiogram and subsequently treated successfully with endovascular embolisation of the aneurysm.

A staged approach to treating oropharyngeal venous malformation

We presented a staged approach to treating oropharyngeal venous malformation in Jehovah Witness patient.

Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy

Refractory hepatic encephalopathy (HE) remains a major cause of morbidity in cirrhosis patients. Large spontaneous portosystemic shunts (SPSSs) have been previously suggested to sustain HE in these patients. We aimed to retrospectively assess the efficacy and safety of patients treated with embolization of large SPSSs for the treatment of chronic therapy-refractory HE in a European multicentric working group and to identify patients who may benefit from this procedure. Between July 1998 and January 2012, 37 patients (Child A6-C13, MELD [Model of Endstage Liver Disease] 5-28) with refractory HE were diagnosed with single large SPSSs that were considered eligible for embolization. On a short-term basis (i.e., within 100 days after embolization), 22 out of 37 patients (59.4%) were free of HE (P < 0.001 versus before embolization) of which 18 (48.6% of patients overall) remained HE-free over a mean follow-up period of 697 ± 157 days (P < 0.001 versus before embolization). Overall, we noted improved autonomy, decreased number of hospitalizations, and severity of the worst HE episode after embolization in three-quarters of the patients. Logistic regression identified the MELD score as strongest positive predictive factor of HE recurrence with a cutoff of 11 for patient selection. As to safety, we noted one major nonlethal procedure-related complication. There was no significant increase in de novo development or aggravation of preexisting varices, portal hypertensive gastropathy, or ascites.

CONCLUSION

This multicenter European cohort study demonstrated a role for large SPSSs in chronic protracted or recurrent HE and substantiated the effectiveness and safety of embolization of these shunts, provided there is sufficient functional liver reserve.

Quality assessment of out sourced after-hours computed tomography teleradiology reports in a Central London University Hospital

The study was designed to assess the quality of out sourced after-hours computed tomography teleradiology service reports. We evaluated 1028 patients over a time period of five month in 2009/2010 (437 female, 591 male, mean age: 51 years, range: 0-97 years) who were referred either by the A&E or other in house departments from 7 pm to 8 am for different reasons. Reporting was done by a teleradiology service provider located in the UK and Australia. Reports were assessed during the routinely performed morning meeting by a panel of in house radiologists. Assessment was done by a five point agreement scale (5="No disagreement", 1="…unequivocal potential for serious morbidity or threat to life"). In 811 (79%) patients no disagreement was found, 164 (16%) were rated as category 4, 40 (4%) as category 3 ("…likelihood of harm is low"). In 13 (1.3%) patients a decision of category 2 was made ("…strong likelihood of moderate morbidity but not threat to life"). No category 1 decision was made. As this was just a discrepancy decision, a follow up of the category 2 patients was done over a period of a maximum of 6 months. In 8 (0.8%) patients the in house reports were correct, in 2 (0.2%) patients the teleradiology service provider was right and in 3 (0.3%) patients the final diagnoses remained unclear. In conclusion there was a small rate (0.8%) of proven serious misinterpretations by the teleradiology service provider, but these were less than in comparable studies with preliminary in house staff reports (1.6-24.6%).

A rare cause of spontaneous intra-abdominal haemorrhage due to coeliac artery stenosis

Coeliac artery stenosis is associated with the formation of collateral vessels from the superior mesenteric artery. High pressure within collateral vessels can lead to the formation of visceral artery aneurysms. Haemorrhage from such aneurysms can be catastrophic if they are not identified and managed promptly. We describe successful arterial embolisation of a pseudoaneurysm arising from a branch of the gastroduodenal artery secondary to coeliac artery stenosis. To the best of our knowledge this is thefirst such reported case in the literature.

Effects of enzyme replacement therapy on the cardiomyopathy of Anderson-Fabry disease: a randomised, double-blind, placebo-controlled clinical trial of agalsidase alfa

BACKGROUND

Anderson-Fabry disease is an X-linked glycosphingolipid storage disorder caused by deficient activity of the lysosomal enzyme alpha-galactosidase A. This leads to a progressive accumulation of globotriaosylceramide (Gb(3)) in the lysosomes of cells throughout the body that ultimately results in premature death from renal, cardiac or cerebrovascular complications. Until recently, there was no effective therapy available for this disease. The present study was designed to assess the safety and efficacy of enzyme replacement therapy with agalsidase alfa on the cardiac manifestations of Anderson-Fabry disease.

METHOD

The effects of therapy with agalsidase alfa on cardiac structure and function were assessed in a randomised, double-blind, placebo-controlled study of 15 adult male patients with Anderson-Fabry disease. The following parameters were measured at baseline and 6 months: left ventricular mass, QRS duration and levels of Gb(3) in cardiac tissue, urine sediment and plasma. After 6 months of the randomised trial patients were enrolled in a 2-year open-label extension study.

RESULTS

Left ventricular mass, as measured by MRI, was significantly reduced following 6 months of treatment with agalsidase alfa compared with placebo (p = 0.041). A mean 20% reduction in myocardial Gb(3) content as assessed by serial transvenous endomyocardial biopsies was demonstrated over the 6 months of enzyme replacement compared to a mean 10% increase in patients receiving placebo (p = 0.42)

CONCLUSION

Enzyme replacement therapy with agalsidase alfa resulted in regression of the hypertrophic cardiomyopathy associated with Anderson-Fabry disease.

Secondary intervention following endovascular repair of abdominal aortic aneurysm: A single centre experience

AIMS

We aim from a review of our early and late experience of secondary intervention for technical failures, to examine and describe the impact of endovascular and open interventions.

METHODS

108 Abdominal Aortic Aneurysms (AAAs) repaired endoluminally between 1995-2001 were analysed. In our early experience, during 1995/96 home made pre-expanded polytetrafluoroethylene grafts fixed with Palmaz stents were used (n = 26). In our later experience, 1997/2001 Talent (n = 70) or Zenith endografts (n = 12) were used. All cases underwent spiral CT at 5 days and 6 monthly intervals post-op. Angiography was performed when further intervention was intended. All technical failures requiring intervention or not were studied.

RESULTS

There were 28 (26%) technical failures identified of which 14 of 26 (54%) occurred in our early experience, and 14 of 86 (16%) occurred in our later experience (p < 0.05). Eleven in all required open conversion at the time of endovascular repair. Our study cohort were the remaining 17 cases requiring secondary intervention, seven were from our early experience and 10 from our later experience. There were 12 endoleaks, including two as a result of graft migration, two graft occlusions, two graft distortions and one graft infection. Overall 10 (66%) technical failures were treated by endoluminal repair and seven (34%) by open methods. However, in our later experience significantly more endoluminal techniques (80%) were used (p < 0.05).

CONCLUSIONS

Technical failure rates were significantly higher in our earlier experience. Open repair, which was a feature of our early experience, has been avoided over the final 3 years. Instead, endoluminal techniques were used without further morbidity or mortality. Aneurysm rupture has not so far been experienced in this experience.

Management of the neck in N0 squamous cell carcinoma of the oral cavity

Mortality in treated squamous cell carcinoma of the oral cavity is most often owing to locoregional failure. In an attempt to improve survival, an aggressive approach to surgical management is often favoured. Although it is generally accepted that the N0 neck should be treated if the risk of micrometastatic disease exceeds 20%, there is little direct support in the literature for this position. A retrospective review of all patients presenting with T1-2, N0 squamous cell carcinoma of the oral cavity treated at the Cancer Control Agency of British Columbia from 1985 to 1994 was conducted. Patients were followed for a minimum of 5 years with documentation of patterns of recurrence and disease-specific survival relative to initial management. The decision regarding management of the neck was frequently made to accommodate treatment of the primary site or reconstructive strategies. Thirteen percent of patients with T1, N0 disease underwent prophylactic neck dissection. No significant difference in outcome was noted in this group. Thirty-three percent of patients with T2, N0 disease underwent prophylactic neck dissection. There was a trend toward improved 5-year survival and lower recurrence rates in the group whose necks were treated, but the difference was not found to be statistically significant. In conclusion, this review showed a trend toward increased survival with prophylactic treatment of the neck in T2, N0 squamous cell carcinoma of the oral cavity, but a larger study would be needed to show a statistically significant benefit.

A multicentre, open, non-comparative phase II study of a combination of fludarabine phosphate, cytarabine and granulocyte colony-stimulating factor in relapsed and refractory acute myeloid leukaemia and de novo refractory anaemia with excess of blasts in transformation

The primary objective of this study was to determine the complete remission (CR) rate achieved with the FLAG (fludarabine phosphate, cytarabine and granulocyte colony-stimulating factor) regimen in patients with relapsed or refractory acute myeloid leukaemia (AML) or de novo refractory anaemia with excess of blasts in transformation (RAEB-t). Secondary objectives were to evaluate survival and toxicity. Induction treatment consisted of between one and two courses of FLAG. Patients achieving CR received between one and two courses of consolidation treatment. Eighty-three of the 89 patients entering the study were eligible for assessment. CR rates were: 17 out of 21 (81%) in late relapse AML (Group 1), 13 out of 44 (30%) in early relapse/refractory AML (Group 2), and 10 out of 18 (56%) in de novo RAEB-t (Group 3). Thirty-four of the 40 responders (85%) achieved CR after one induction course. Median survival times were 1.4 years, 3 months and 1.6 years in Groups 1, 2 and 3 respectively. Other than myelosuppression, the FLAG regimen was not generally associated with clinically significant toxicity and was well tolerated by most patients including the elderly. The FLAG regimen offers a very effective alternative treatment for CR induction in poor prognosis adult patients with either relapsed or refractory AML or de novo RAEB-t. FLAG delivers high-dose treatment without increasing overall toxicity, an approach which is of particular value in older patients, who constitute the majority in these diseases. It is therefore an important advance in developing new treatment options for these patients.

Inhibition of respiratory and bioenergetic mechanisms by hydrogen sulfide in mammalian brain

The biochemical effects of hydrogen sulfide were investigated by treating enzyme homogenates and synaptosomes prepared from mammalian brain with sodium sulfide. Brain cytochrome c oxidase activity was highly sensitive to inhibition by sodium sulfide, as demonstrated by an IC50 of 0.13 microM. Sodium sulfide was also found to inhibit carbonic anhydrase activity in cerebellum, frontal cortex, and hippocampus. Synaptosomal oxygen consumption was significantly reduced as the concentration of sodium sulfide was increased from 20 to 100 microM; this was accompanied by a concentration-dependent depolarization of the synaptosomal mitochondrial membrane in situ and a reduction in synaptosomal ATP concentration. In other experiments using synaptosomes, sodium sulfide caused a significant calcium-independent increase in the extracellular accumulation of L-glutamate, inhibited Na+-dependent uptake of [3H]glutamate, but was unable to influence intrasynaptosomal free ionic Ca2+. Parallel studies conducted in vivo showed that rats exposed over a 5-d period to hydrogen sulfide (100 ppm for 3 h/d) had significantly higher concentrations of L-glutamate in the hippocampus compared to control animals. In summary, our results indicate that sulfide causes extensive disruption to respiratory and related mitochondrial functions in mammalian brain in vitro. The reduced capacity of nerve endings to take up L-glutamate may contribute to the raised L-glutamate levels observed in vivo.

Early management and postnatal investigation of prenatally diagnosed hydronephrosis

The prime objective of this study was to assess the benefits and practicalities of an investigation protocol to identify, follow-up and investigate fetal uropathies in a manner to maximize efficiency. Over a one-year-period, antenatal ultrasound examinations were performed on 4268 consecutive pregnancies. Eighty fetuses had renal tract dilatation; these were followed up postnatally according to the protocol; 17 had significant structural abnormalities requiring further follow-up. Hospital attendances were estimated to have been reduced by approximately 66% through the use of the protocol. The protocol for investigation and management of these patients is presented. The system implemented worked very smoothly and the subsequent findings and implications are discussed.