Human iPSC and CRISPR targeted gene knock-in strategy for studying the somatic TIE2L914F mutation in endothelial cells

Induced pluripotent stem cell (iPSC) derived endothelial cells (iECs) have emerged as a promising tool for studying vascular biology and providing a platform for modelling various vascular diseases, including those with genetic origins. Currently, primary ECs are the main source for disease modelling in this field. However, they are difficult to edit and have a limited lifespan. To study the effects of targeted mutations on an endogenous level, we generated and characterized an iPSC derived model for venous malformations (VMs). CRISPR-Cas9 technology was used to generate a novel human iPSC line with an amino acid substitution L914F in the TIE2 receptor, known to cause VMs. This enabled us to study the differential effects of VM causative mutations in iECs in multiple in vitro models and assess their ability to form vessels in vivo. The analysis of TIE2 expression levels in TIE2L914F iECs showed a significantly lower expression of TIE2 on mRNA and protein level, which has not been observed before due to a lack of models with endogenous edited TIE2L914F and sparse patient data. Interestingly, the TIE2 pathway was still significantly upregulated and TIE2 showed high levels of phosphorylation. TIE2L914F iECs exhibited dysregulated angiogenesis markers and upregulated migration capability, while proliferation was not affected. Under shear stress TIE2L914F iECs showed reduced alignment in the flow direction and a larger cell area than TIE2WT iECs. In summary, we developed a novel TIE2L914F iPSC-derived iEC model and characterized it in multiple in vitro models. The model can be used in future work for drug screening for novel treatments for VMs.

Effectiveness of polidocanol sclerotherapy in alleviating symptoms in patients with venous malformations

OBJECTIVE

The objective of this study was to retrospectively evaluate the effectiveness of polidocanol in managing pain, swelling, functional limiting and cosmetic disorders in patients with venous malformations (VMs).

METHODS

This retrospective study included patients who underwent sclerotherapy with polidocanol for VMs between 2020 and 2022. Patient records, imaging findings, and evaluation questionnaires used in the preprocedure and follow-up phases were reviewed. After sclerotherapy, patients were followed up at 1, 2, 3, and 6 months. During these visits, the previously used 11-point verbal numerical rating scale (from 0 [no pain] to 10 [worst pain thinkable]) was used to evaluate the severity of symptoms such as pain, swelling, cosmetic discomfort, and functional limitation, and patients were asked to report the number of days per week they experienced these symptoms owing to the VM.

RESULTS

A total of 194 sclerotherapy procedures (mean, 1.6 ± 0.3 procedures) in 84 patients (55 female and 29 male patients; mean age, 22.45 ± 11.83 years) were conducted. The majority of these malformations (81%, or 68 patients) were located in the extremities. We found a significant decrease in pain, swelling, functional limitation, cosmetic appearance, and number of painful days between all time points, except for the comparison between months 3 and 6 (P < .001) CONCLUSIONS: Polidocanol sclerotherapy is a safe and effective treatment for VMs that significantly decreases patient complaints and has a very low complication rate. Particularly, following patients at short intervals and administering additional sclerotherapy sessions when necessary will significantly increase patient satisfaction.

Management of Midfacial and Skull Vault Osseous Vascular Lesions

There continuous to be widespread misuse of nomenclature used to described vascular anomalies, This is even more pronounced in the case of intra-osseous lesions. Bone involvement is more common with vascular malformations and extremely rare in haemangiomas. An accurate diagnosis is mandatory for tailored management and often based on a thorough history, clinical examination, and cross-sectional imaging. Surgery remains the main stay for the management of symptomatic venous malformations. Embolisation with or without surgery is the main stay for arteriovenous malformations. Virtual surgical planning, with surgical guides and patient specific implants help achieve predictably excellent results.

Study of vascular sclerosing agent based on the dual mechanism of vascular endothelial cell damage-plasmin system inhibition

Venous malformations are a vascular disorder. Currently, the use of chemical sclerosing agents is a common clinical approach for the treatment of venous malformations. However, the effectiveness of existing sclerosing agents is unsatisfactory and often accompanied by severe side effects. In this study, we have developed a novel cationic surfactant-based sclerosing agent (POL-TA) by conjugating the plasmin inhibitor tranexamic acid (TA) with a nonionic surfactant polidocanol (POL) through an ester bond. POL-TA induces endothelial cell damage, triggering the coagulation cascade and thrombus formation. Moreover, it releases TA in vivo, which inhibits plasmin activity and the activation of matrix metalloproteinase (MMPs), thereby stabilizing the fibrin network of the thrombus and promoting vascular fibrosis. We have established a cell model using venous malformation endothelial cells and assessed the cellular damage and underlying mechanisms of POL-TA. The inhibitory effects of POL-TA on the plasmin-MMPs system were evaluated using MMP-9 activity assay kit. Additionally, the mice tail vein model was employed to investigate the vascular sclerosing effects and mechanisms of POL-TA.

Mechanism of LEF1-AS1 regulating HUVEC cells by targeting miR-489-3p/S100A11 axis

Background

The venous malformation is the most common congenital vascular malformation and exhibits the characteristics of local invasion and lifelong progressive development. Long noncoding RNA (lncRNA) regulates endothelial cells, vascular smooth muscle cells, macrophages, vascular inflammation, and metabolism and also affects the development of venous malformations. This study aimed to elucidate the role of the lncRNA LEF1-AS1 in the development of venous malformations and examine the interaction among LEF1-AS1, miR-489-3p, and S100A11 in HUVEC cells.

Methods

Venous malformation tissues, corresponding normal venous tissues, and HUVEC cells were used. Agilent human lncRNA microarray gene chip was used to screen differential genes, RNA expression was detected using quantitative reverse transcription PCR, and protein expression was detected using Western blotting. The proliferation, migration, and angiogenesis of HUVEC cells were assessed using CCK8, transwell, and in vitro angiogenesis tests.

Results

A total of 1,651 lncRNAs were screened using gene chip analysis, of which 1015 were upregulated and 636 were downregulated. The lncRNA LEF1-AS1 was upregulated with an obvious difference multiple, and the fold-change value was 11.03273. The results of the analysis performed using the StarBase bioinformatics prediction website showed that LEF1-AS1 and miR-489-3p possessed complementary binding sites and that miR-489-3p and S100A11 also had complementary binding sites. The findings of tissue experiments revealed that the expressions of LEF1-AS1 and S100A11 were higher in tissues with venous malformations than in normal tissues, whereas the expression of miR-489-3p was lower in venous malformations than in normal tissues. Cell culture experiments indicated that LEF1-AS1 promoted the proliferation, migration, and angiogenesis of HUVEC cells. In these cells, LEF1-AS1 targeted miR-489-3p, which in turn targeted S100A11. LEF1-AS1 acted as a competitive endogenous RNA and promoted the expression of S100A11 by competitively binding to miR-489-3p and enhancing the proliferation, migration, and angiogenesis of HUVEC cells. Thus, LEF1-AS1 participated in the occurrence and development of venous malformation.

Conclusions

The expression of LEF1-AS1 was upregulated in venous malformations, and the expression of S100A11 was increased by the adsorption of miR-489-3p to venous endothelial cells, thus enhancing the proliferation, migration, and angiogenesis of HUVEC cells. In conclusion, LEF1-AS1 is involved in the occurrence and development of venous malformations by regulating the miR-489-3p/S100A11 axis, which provides valuable insights into the pathogenesis of this disease and opens new avenues for its treatment.

Health-related quality of life in children with congenital vascular malformations

A cross-sectional study was performed to evaluate health-related quality of life (HRQOL) in children with congenital vascular malformations (CVM) and to investigate factors associated with an impaired HRQOL. Children (2-17 years) with CVMs who visited the HECOVAN expertise center between 2016-2018 were included. The PedsQL 4.0 Generic Core Scales were used and a score ≥ 1.0 SD below the normative mean was defined as an impaired HRQOL. Factors associated with impairment were investigated using univariate and multivariate logistic regression analysis. The median overall HRQOL was 84.8/100 (n = 207; 41% boys, 59% girls; self-reported IQR 73.9-92.4 and parent-reported IQR 71.4-92.4). Patients aged 13-17 years reported significantly worse physical functioning than those aged 8-12 years (median 84.4, IQR 71.1-93.8 versus median 90.6, IQR 81.3-96.9; p = 0.02). Parents reported a significantly lower overall HRQOL than their children (median 80.4, IQR 70.7-90.8 versus median 85.9, IQR 76.1-92.4; p = 0.001). HRQOL was impaired in 25% of patients. Impairment occurred significantly more often in lower extremity CVMs (38%, p = 0.01) and multifocal CVMs (47%, p = 0.01) compared to CVMs in the head/neck region (13%). Other associated factors included invasive management (31% versus 14%; p = 0.01), age at first treatment ≤ 5 years (48% versus 25%; p = 0.02) and ongoing treatment (38% versus 18%; p = 0.004). After correction for other factors, significance remained for lower extremity CVMs and ongoing invasive treatment.

CONCLUSIONS

Overall median HRQOL was reasonable and not significantly different from the norm sample. Parental ratings were significantly lower than their children's ratings. A quarter of the patients had an impaired HRQOL, which seemed to worsen with age. Independently associated factors included a lower extremity CVM and invasive management.

WHAT IS KNOWN

• Congenital vascular malformations could affect health-related quality of life (HRQOL). • Studies on pediatric patients are limited and either very small or in combination with adult patient series.

WHAT IS NEW

• This study raises awareness of an impaired HRQOL in 25% of pediatric patients with congenital vascular malformations. • Associated factors included a lower extremity CVM and invasive management.

Surgical Resection of Vulvar Labial Venous Malformations: A Single Center Experience

BACKGROUND

Venous malformations (VMs) involving the vulva are rare but often cause debilitating pain, aesthetic concern, and functional impairment. Treatment with medical therapy, sclerotherapy, operative resection, or a combination thereof may be considered. The optimal therapeutic approach remains unclear. We report our experience resecting labial VMs in a large cohort of patients.

METHODS

A retrospective review of patients who underwent partial or complete resection of a labial VM was conducted.

RESULTS

Thirty-one patients underwent forty-three resections of vulvar VMs between 1998 and 2022. Physical examination and imaging demonstrated: 16% of patients had focal labial lesions, 6% had multifocal labial lesions, and 77% had extensive labial lesions. Indications for intervention included pain (83%), appearance (21%), functional impairment (17%), bleeding (10%), and cellulitis (7%). Sixty-one percent of patients underwent a single resection, 13% multiple partial resections, and 26% a combination of sclerotherapy and operative resection(s). Median age was 16.3 years at first operation. All patients requiring multiple operations had extensive VMs. Median blood loss was 200 mL. Postoperative complications included wound infection/dehiscence (14%), hematoma (2%), and urinary tract infection (2%). The median follow-up assessment was 14 months: 88% of patients had no complaints and 3 patients were experiencing recurrent discomfort.

CONCLUSIONS

Surgical resection is a safe and effective approach to treating vulvar labial VMs. Patients with focal or multifocal VMs can be successfully treated with a single resection, whereas patients with an extensive VM may require multiple partial resections or combined sclerotherapy and resection(s) to achieve long-term control.

TYPE OF STUDY

Retrospective Study.

LEVEL OF EVIDENCE

IV.

Value of fat-suppressed T2-weighted imaging for predicting short-term pain relief after sclerotherapy for venous malformations in the extremities

PURPOSE

This study aimed to evaluate the value of fat-suppressed T2-weighted imaging (FS-T2WI) for predicting short-term pain relief after polidocanol sclerotherapy for painful venous malformations (VMs) in the extremities.

MATERIALS AND METHODS

This retrospective study included patients with painful VMs in the extremities between October 2014 and September 2021, had their first sclerotherapy without history of surgical therapy, and underwent magnetic resonance imaging before sclerotherapy. Pain relief was assessed 2 months after 3% polidocanol sclerotherapy and was categorized as follows: progression, no change, partial relief, or free of pain. The associations between pain relief and imaging features on FS-T2WI were analyzed.

RESULTS

The study included 51 patients. The no change, partial relief, and free of pain groups included 6 (11.8%), 25 (49.0%), and 20 (39.2%) patients, respectively. No patient experienced progressive pain. The lesion diameter was ≤ 50 mm in 13 (65.0%) patients in the free of pain group, whereas it was > 50 mm in all patients in the no change group (p = 0.019). The lesions showed well-defined margin in 15 (75.0%) patients in the free of pain group, whereas they showed ill-defined margin in 5 (83.3%) patients in the no change group (p = 0.034). The most common morphological type was cavitary in the free of pain group (14 [70.0%] patients), whereas there was no patient with cavitary type lesion in the no change group (p = 0.003). Drainage vein was demonstrated in 6 (100%), 22 (88.0%), and 11 (55.0%) patients in the no change, partial relief, and free of pain group, respectively (p = 0.011).

CONCLUSION

A lesion size of 50 mm or less, a well-defined margin, a cavitary type, and no drainage vein on FS-T2WI were significant features for predicting short-term pain relief after polidocanol sclerotherapy for painful VMs in the extremities.

Targeted next-generation sequencing for detection of PIK3CA mutations in archival tissues from patients with Klippel-Trenaunay syndrome in an Asian population : List the full names and institutional addresses for all authors

BACKGROUND

Klippel-Trenaunay syndrome (KTS) is a rare slow-flow combined vascular malformation with limb hypertrophy. KTS is thought to lie on the PIK3CA-related overgrowth spectrum, but reports are limited. PIK3CA encodes p110α, a catalytic subunit of phosphatidylinositol 3-kinase (PI3K) that plays an essential role in the PI3K/AKT/mammalian target of rapamycin (mTOR) signaling pathway. We aimed to demonstrate the clinical utility of targeted next-generation sequencing (NGS) in identifying PIK3CA mosaicism in archival formalin-fixed paraffin-embedded (FFPE) tissues from patients with KTS.

RESULTS

Participants were 9 female and 5 male patients with KTS diagnosed as capillaro-venous malformation (CVM) or capillaro-lymphatico-venous malformation (CLVM). Median age at resection was 14 years (range, 5-57 years). Median archival period before DNA extraction from FFPE tissues was 5.4 years (range, 3-7 years). NGS-based sequencing of PIK3CA achieved an amplicon mean coverage of 119,000x. PIK3CA missense mutations were found in 12 of 14 patients (85.7%; 6/8 CVM and 6/6 CLVM), with 8 patients showing the hotspot variants E542K, E545K, H1047R, and H1047L. The non-hotspot PIK3CA variants C420R, Q546K, and Q546R were identified in 4 patients. Overall, the mean variant allele frequency for identified PIK3CA variants was 6.9% (range, 1.6-17.4%). All patients with geographic capillary malformation, histopathological lymphatic malformation or macrodactyly of the foot had PIK3CA variants. No genotype-phenotype association between hotspot and non-hotspot PIK3CA variants was found. Histologically, the vessels and adipose tissues of the lesions showed phosphorylation of the proteins in the PI3K/AKT/mTOR signaling pathway, including p-AKT, p-mTOR, and p-4EBP1.

CONCLUSIONS

The PI3K/AKT/mTOR pathway in mesenchymal tissues was activated in patients with KTS. Amplicon-based targeted NGS could identify low-level mosaicism from low-input DNA extracted from FFPE tissues, potentially providing a diagnostic option for personalized medicine with inhibitors of the PI3K/AKT/mTOR signaling pathway.

Outcome after surgical treatment of venous malformations of the hand in childhood

OBJECTIVE

Surgical treatment of venous malformations (VMs) of the hand is challenging. The hand's small functional units, dense innervation, and terminal vasculature can be easily compromised during invasive interventions like surgery or sclerotherapy, leading to an increased risk of functional impairment, cosmetic consequences, and negative psychological effects.

METHODS

We have conducted a retrospective review of all surgically treated patients diagnosed with VMs of the hand between 2000 and 2019 and evaluated their symptoms, diagnostic investigations, complications, and recurrences.

RESULTS

Twenty-nine patients (females, n = 15) with a median age of 9.9 years (range, 0.6-18 years) were included. Eleven patients presented with VMs involving at least one of the fingers. In 16 patients, the palm and/or dorsum of the hand was affected. Two children presented with multifocal lesions. All patients presented with swelling. Preoperative imaging was done in 26 patients and consisted of magnetic resonance imaging in nine patients, ultrasound in eight patients, and both modalities in nine patients. Three patients underwent surgical resection of the lesions without any imaging. Indications for surgery were pain and restriction of function (n = 16), and when lesions were preoperatively evaluated as completely resectable (n = 11). In 17 patients, a complete surgical resection of the VMs was performed, whereas in 12 children, an incomplete resection of VM was deemed due to nerve sheath infiltration. At a median follow-up of 135 months (interquartile range, 136.5 months; range, 36-253 months), recurrence occurred in 11 patients (37.9%) after a median time of 22 months (range, 2-36 months). Eight patients (27.6%) were reoperated because of pain, whereas three patients were treated conservatively. The rate of recurrences did not significantly differ between patients presenting with (n = 7 of 12) or without (n = 4 of 17) local nerve infiltration (P = .119). All surgically treated patients who were diagnosed without preoperative imaging developed a relapse.

CONCLUSIONS

VMs in the region of the hand are difficult to treat, and surgery is associated with a high recurrence rate. Accurate diagnostic imaging and meticulous surgery may contribute to improve the outcome of the patients.

Venous malformations of the lower limb with severe localized intravascular coagulopathy treated with radiofrequency ablation and resection

Diffuse venous malformations (VMs) are relatively rare, especially the lesions locting special anatomical sites, and they are prone to casuse localized intravascular coagulopathy (LIC). Diffuse VMs can also cause bleeding and life-threatening disseminated intravascular coagulopathy (DIC) from trauma, surgery, and improper treatments. Thus, the treatment of diffuse VMs with LIC is quite tough. We report of a diffuse VMs with severe LIC that was treated with the combined use of minimally invasive treatment and open surgery.

Large intra-abdominal venous malformations in associated with inferior vena cava aneurysm

Intra-abdominal venous malformations and inferior vena cava aneurysms are rare and difficult to diagnose because of their nonspecific clinical symptoms. These vascular anomalies are important entities due to the risk of thrombosis or rupture. According to the classification of International Society for the Study of Vascular Anomalies, venous malformations are classified as low-flow vascular anomalies, showing absence of arterial and early venous enhancement and slow gradual filling with contrast on delayed venous imaging. Phleboliths related to thrombosis and calcifications, are the key finding of venous malformations. In this article, we report an exceptional case of large intra-abdominal venous malformations in associated with an inferior vena cava aneurysm.

American society of pediatric otolaryngology vascular anomalies task force review of tongue venous malformations: Techniques, pearls, and pitfalls

Management of tongue venous malformations can be challenging in the pediatric population due to their heterogeneity in presentation, extent of involvement and functional compromise. It is important to recognize the value of various treatment options in order to guide management of each patient in an individualized fashion. Here we describe a series of patients with tongue venous malformations that are managed using diverse modalities to illustrate the relative benefits and risks of each technique. The challenges of venous malformation treatment can be mitigated by tailoring the approach to each individual patient and malformation. This case series also emphasizes the need and importance of working in the setting of a multidisciplinary vascular anomalies team.

A systematic review and network meta-analysis of the effectiveness of sclerotherapy for venous malformation

OBJECTIVE

Sclerotherapy for venous malformation has been widely used; however, no guidelines are available to assess the effectiveness of different sclerotherapy agents. We conducted a systematic review and network meta-analysis to investigate the effectiveness of sclerotherapy agents for venous malformations.

METHODS

Three electronic databases were searched from their inception (1950) to April 29, 2021. Studies comparing the effectiveness of different sclerotherapy agents were included. The risk of bias within and across studies was assessed. Pairwise meta-analyses were conducted, followed by a network meta-analysis. We also assessed inconsistency and publishing bias using various approaches.

RESULTS

Seven studies with 547 patients in six arms were included in the present study. We defined the response and complete response as two separate outcomes. Significant differences were observed in four comparisons with respect to the response (ethanol vs bleomycin, ethanol vs polidocanol, ethanol vs sodium tetradecyl sulfate, polidocanol vs sodium tetradecyl sulfate). No statistically significant differences were found in the other comparisons. The evidence network revealed that for the response outcome, ethanol ranked first, followed by pingyangmycin, polidocanol, sodium morrhuate, bleomycin, and, finally, sodium tetradecyl sulfate. For the complete response outcome, pingyangmycin had the best results, followed by sodium morrhuate, polidocanol, ethanol, bleomycin, and, finally, sodium tetradecyl sulfate. Major complications, such as facial nerve palsy, serious local swelling, and necrosis, had occurred mostly in the ethanol group and rarely in the other groups. Because of the limited data, no further analysis of major complications was conducted. Our confidence in the comparisons and rankings was low. We found no verified inconsistency or publishing bias in the present study using the existing approaches.

CONCLUSIONS

Ethanol showed a significantly better response statistically compared with the other agents. However, ethanol had also resulted in the highest incidence of complications. Pingyangmycin showed the second-best response, best complete response, and a low rate of complications, respectively. Overall, pingyangmycin achieved excellent performance and balance in terms of the different outcomes. However, they could not be adequately recommended from the available data. More superior trials, especially randomized controlled trials, are needed in the future.

A case of two shunts in the endovascular treatment of type II Abernethy syndrome

Background

Abernethy malformation is a rare condition defined by a congenital extrahepatic portosystemic shunt, often leading to absence or hypoplasia of the intrahepatic portal venous system. Although there are no consensus treatment guidelines, interventional techniques now offer minimally invasive treatment options for Abernethy malformations. This case report describes a case of Abernethy Syndrome Type II where the patient had two separate extrahepatic portosystemic shunts treated with endovascular occlusion with two Amplatzer plugs and demonstrates the feasibility of this treatment for this rare condition. This case was in a young adult, adding to the scarce literature of treatment for Abernethy syndrome in the adult population.

Case presentation

We report a case of a 20-year-old female patient with neurocognitive behavioral difficulty, voracious appetite, and chronic encephalopathy secondary to type II Abernethy malformation with not one, but two extrahepatic portosystemic shunts. The patient had failed medical management and was not a liver transplant candidate. Therefore, she presented to us for an endovascular treatment option. The two shunts were treated with endovascular occlusion using Amplatzer vascular plugs. Following embolization, flow into the hypoplastic portal vein improved with near complete occlusion of flow into the portosystemic shunts, thus restoring blood flow into the native portal system. At 3 month follow up, a CT demonstrated complete occlusion of the two portosystemic shunts, and a portal vein diminutive in caliber. The portal vein measured 7 mm in diameter on both pre and post-procedure CT scans. The total volume of the liver was found to be 843 cm3 on pre-procedure CT & 1191 cm3 on post-procedure CT.

Conclusions

This report demonstrates the feasibility of using endovascular embolization to treat Abernethy II malformations. The management strategy of Type II Abernethy Syndrome should be to redirect blood flow into the hypoplastic native portal system, allowing for physiologic hepatic metabolism of splanchnic blood, hypertrophy of the portal system, and growth of the liver from the increased trophic flow.

Downregulation of microRNA-21 contributes to decreased collagen expression in venous malformations via transforming growth factor-β/Smad3/microRNA-21 signaling feedback loop

OBJECTIVE

Venous malformations (VMs) are the most frequent vascular malformations and are characterized by dilated and tortuous veins with a dysregulated vascular extracellular matrix. The purpose of the present study was to investigate the potential involvement of microRNA-21 (miR-21), a multifunctional microRNA tightly associated with extracellular matrix regulation, in the pathogenesis of VMs.

METHODS

The expression of miR-21, collagen I, III, and IV, transforming growth factor-β (TGF-β), and Smad3 (mothers against decapentaplegic homolog 3) was evaluated in VMs and normal skin tissue using in situ hybridization, immunohistochemistry, Masson trichrome staining, and real-time polymerase chain reaction. Human umbilical vein endothelial cells (HUVECs) were used to explore the underlying mechanisms.

RESULTS

miR-21 expression was markedly decreased in the VM specimens compared with normal skin, in parallel with downregulation of collagen I, III, and IV and the TGF-β/Smad3 pathway in VMs. Moreover, our data demonstrated that miR-21 positively regulated the expression of collagens in HUVECs and showed a positive association with the TGF-β/Smad3 pathway in the VM tissues. In addition, miR-21 was found to mediate TGF-β-induced upregulation of collagens in HUVECs. Our data have indicated that miR-21 and the TGF-β/Smad3 pathway could form a positive feedback loop to synergistically regulate endothelial collagen synthesis. In addition, TGF-β/Smad3/miR-21 feedback loop signaling was upregulated in bleomycin-treated HUVECs and VM specimens, which was accompanied by increased collagen deposition.

CONCLUSIONS

To the best of our knowledge, the present study has, for the first time, revealed downregulation of miR-21 in VMs, which might contribute to decreased collagen expression via the TGF-β/Smad3/miR-21 signaling feedback loop. These findings provide new information on the pathogenesis of VMs and might facilitate the development of new therapies for VMs.

Operative management of equinus associated with lower limb venous malformations

OBJECTIVES

Functional impairment is a common complaint in patients with venous malformations. Equinus can occur when the venous malformation involves the lower limb, a challenging condition with only a few studies to guide treatment choices. This study was aimed to investigate the operative management of equinus associated with lower limb venous malformations.

METHOD

Between August 2015 and September 2017, a total of 12 patients presented with equinus associated with lower limb venous malformations and underwent surgical correction. Preoperative and postoperative clinical symptoms, physical examination and orthopaedic evaluation were retrospectively reviewed. 8 patients who experienced pain underwent percutaneous sclerotherapy prior to the operation. Surgical management included gastrocnemius intramuscular aponeurotic recession, Z-lengthening of the Achilles tendon, Hoke technique and Taylor Spatial Frame external fixation.

RESULTS

There were eight female and four male patients with a mean age of 14.3 ± 5.9 years. The mean follow-up period was 34.8 ± 9 months. The range of motion of ankle dorsiflexion (with knee extended) improved for each patient (mean, 25.4 degrees; standard deviation, 8.5 degrees). No neurovascular complications were observed.

CONCLUSION

Operative correction of equinus associated with lower limb venous malformations is safe and effective. Selective preoperative sclerotherapy is necessary for optimal outcomes.

Servelle-Martorell syndrome in an adult: A case report with findings on CT angiography

Servelle-Martorell syndrome, also known as angio-osteohypotrophic syndrome, is a congenital venous malformation that rarely involves the arterial system. There are many different, mainly conservative, treatment methods. We present the case of a 28-year-old woman with a history of left arm and back lesions, which appeared at birth and had enlarged over time. She had been diagnosed with a vascular malformation but had not yet received treatment. She presented to our hospital with numbness in her left arm and was diagnosed with Servelle-Martorell syndrome based on computed tomography (CT) angiography. This case emphasizes that CT angiography is a useful modality for evaluating the extent of the venous malformations in patients with Servelle-Martorell syndrome.

The Addition of Lipid-Based Contrast Medium does not Inactivate the Detergent Sclerosant Sodium Tetradecyl Sulfate in-vitro

PURPOSE

To investigate if the detergent sclerosant sodium tetradecyl sulfate (STS) is deactivated by the lipid-based contrast agent ethiodised oil.

METHOD

3% STS was mixed with ethiodised oil and room air in a 2:1:4 ratio in two luer lock syringes and a three way connector and agitated to make foam (the Tessari technique) to replicate the clinical use of the products. The assay of STS in the mixture was assessed using the British Pharmacopoeia method. Briefly this is a manual titration method where the solution of STS is mixed with an indicator solution and titrated with hyamine solution of known concentration; the concentration of the STS can then be calculated with the titration results. To further mimic the clinical environment with the presence of blood, the effect of adding increasing amounts of albumin to the STS-ethiodised oil mixture was assessed.

RESULTS

The assay of STS in the solution after mixing with ethiodised oil was 3% indicating that the ethiodised oil did not deactivate the STS. The addition of albumin to the STS-contrast mixture resulted in near linear neutralisation of the STS with increasing concentrations in the same quantities as with STS alone.

CONCLUSIONS

The mixture of the lipid-based contrast agent ethiodised oil with the detergent sclerosant STS did not affect the availability of the sclerosant. The continued use of STS-ethiodised oil in the management of vascular malformations can be supported.

Endoscopic Multimodal Approach to the Treatment of Airway Venous Malformations

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An inferior vena cava discontinuity with an hepato-renal accessory vein development: A radio-anatomical morphometric case study

PURPOSE

Inferior vena cava (IVC) agenesis is an uncommon congenital vascular anomaly stemming from aberrant development during embryogenesis. It results from the failure of one or more of the supracardinal veins, subcardinal veins, vitelline veins or postcardinal veins to connect. The symptomatology resulting from this vascular malformation can be either absent or extremely rich and varied.

METHODS

Thoracoabdominal-pelvic CT scan projections following iodine-based contrast product injection were analyzed and a three-dimensional model of vascularization constructed.

RESULTS

Herein, an asymptomatic case of IVC agenesis with absence of the suprarenal and renal segments, with azygos continuation, presenting an accessory hepatorenal vein is reported. The presence of this type of accessory vein has never been described in the literature to date. The etiology of this case of IVC agenesis is explored in depth. We also analyzed the morphometric parameters of the IVC remnant segments and the azygos vein in order to quantify the dilatation of the collateral venous pathway overdeveloped to handle blood return.

CONCLUSION

Using the findings from this case and those reported in the literature, we provide general recommendations that should be taken into account before managing a patient, symptomatic or asymptomatic, admitted to the hospital with IVC agenesis.

Chiari I malformation with Klippel-Trenaunay syndrome: case report and review of the literature

We present a rare case of an 8-year-old male with Klippel-Trenaunay syndrome (KTS) and a Chiari I malformation (CIM). Magnetic resonance imaging (MRI) to investigate facial asymmetry and speech delay at age two revealed CIM with cerebellar tonsils 1.3 cm below the foramen magnum without syringomyelia. The patient underwent a craniectomy and posterior fossa decompression with C1 laminectomy. While gene sequencing determined the patient was negative for the PIK3CA gene mutation, the patient's clinical history strongly suggests KTS. He has hemihypertrophy, leg length discrepancy, hemangiomas and pigmentary mosaicism along the upper and lower extremities, heart murmur, chronic low heart rate, recurrent hip pain, and mild scoliosis. Neurodevelopmental concerns include difficulty reading, attention deficit hyperactivity disorder (ADHD), anxiety, and difficulty running and going downstairs. His most recent MRI shows good decompression at the cervicomedullary junction, global cerebrospinal fluid (CSF) flow, and less peg-like cerebellar tonsils. Also noted were two intravertebral hemangiomas at T5 and T6. While the patient's speech has improved, there is still difficulty with the expressive language. He still has mild delays, runs slowly, and does not alternate feet when climbing stairs. The patient is being followed by multiple specialists including neurology, hematology-oncology, genetics, orthopedic surgery, and developmental pediatrics.

Late-onset multiple venous malformations confined to the upper limb: link to somatic MAP3K3 mutations

Venous (cavernous) malformations are commonly seen in the upper limb. Almost all venous malformations are congenital. They may be sporadic, familial, or syndromic. Late-onset, multiple venous malformations confined to the upper limb are rare. Lesions present after puberty. All previously reported cases were located subcutaneously and were small in size. The condition is non-hereditary and non-syndromic. We present a unique series of eight patients with this rare condition. Unique features included the presence of large malformations (up to 20 cm in diameter) and the presence of subfascial lesions causing nerve compression. Surgical excision was curative. Mutational analysis in one patient identified a novel somatic MAP3K3 gene mutation (c.1723T > C, p.Tyr 575 His) in the affected veins. The encoded MAP3K3 protein is known to accelerate the RAS pathway of cellular proliferation.Level of evidence: IV.

Genetic landscape of common venous malformations in the head and neck

OBJECTIVE

Common venous malformations (VMs) are a frequent sporadic subtype of vascular malformations. Given the TEK and PIK3CA mutations identified, this study aims to investigate the genetic landscape of VMs in the head and neck.

METHODS

Patients from published sequencing studies related to common VMs were reviewed. Detailed data regarding clinical characteristics, sequencing strategies, and mutation frequency were synthesized. Lesion distribution of common VMs in the head and neck were further retrospectively analyzed by the pathologic database of the Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital. For the frequently affected sites in the head and neck, patients were selected for targeted sequencing with a designed vascular malformation-related gene panel or whole exome sequencing. Detected variants were analyzed by classical bioinformatic algorithms (SIFT23, PolyPhen-2 HDIV, LRT, MutationTaster, Mutation Assessor, and GERP++). To confirm the expression pattern of particular candidate gene, specimens were examined histochemically. Gene ontology enrichment analysis and a protein-protein interaction network were also constructed.

RESULTS

Three hundred patients from eight sequencing studies related to common VMs were reviewed. The total prevalence rates of TEK and PIK3CA mutations were 41.3% and 26.7%, respectively. The most frequent TEK/PIK3CA mutations were TEK-L914F/PIK3CA-H1047R. TEK/PIK3CA mutations existed in 70.3% and 2.7% of VMs in the head and neck. In retrospective data from 649 patients carrying cervicofacial VMs at Shanghai Ninth Hospital, the most frequent sites were the maxillofacial region (lips, cheek, parotid-masseteric region, submandibular region) and the oral and oropharyngeal region (buccal mucosa, tongue). Targeted sequencing for 14 frequent lesions detected TEK variants in three patients (21.4%), but no PIK3CA mutations. On whole exome sequencing of two patients without TEK/PIK3CA mutations, CDH11 was the only shared deleteriously mutated gene. Bioinformatic analyses of CDH11 implied that genes involved in cellular adhesion and junctions formed a significant portion.

CONCLUSIONS

Common VMs of the head and neck have a unique genetic landscape. Novel CDH11 and TEK variants imply that pathogenesis is mediated by the regulatory relationship between endothelial cells and extracellular components.

Surgical treatment of vulvar venous malformations without preoperative sclerotherapy: Outcomes of 18 patients

BACKGROUND

Our aim was to evaluate the benefit of surgical resection of the venous malformations (VMs) of the external female genitalia.

METHODS

Over the period of 2009-2019, 18 consecutive females underwent surgical resection for vulvar VM. Evaluations included preoperative Doppler ultrasound, MRI, and pre-and postoperative photographic imaging. The main outcomes were: residual pain, cosmetic distortion, residual VM, and quality of life.

RESULTS

Over a 10 year periods, 18 females, mean age 35 years (range 9-71) were included in this study. All patients were symptomatic: 16 had intermittent pain or discomfort, 1 had bleeding and 2 requested cosmetic treatment. Of these cases, there were 5 isolated vulvar VM, 12 associated VM: 3 of the clitoral hood, 3 troncular pelvic vein insufficiency and 12 of the lower limb. Eight patients had undergone previous procedures: 2 sclerotherapy treatments (1-3 sessions), 4 partial surgical resections. There were 18 single resections in the vulva (7 focal, 11 complete), 2 partial resections in clitoral hood and 2 had resection of a VM in the perirtoneovaginal canal at the same time. The mean follow-up was 42. 9 months (range 6-120). Two patients were lost to followup at 6 months. For all patients, elimination of pain and soft tissue redundancy was achieved. Two patients had persistent discomfort and 2 requested cosmetic treatment.

CONCLUSION

Surgical resection of vulvar VM can be the best approach with few postoperative complications, good functional and cosmetic results. Appropriate preoperative evaluation is required to identify isolated VM or VM associated with ovarian vein or internal iliac vein insufficiency requiring to be treated before surgery.

Cavernous Sinus Hemangioma: Imaging Diagnosis and Surgical Considerations

BACKGROUND

Cavernous sinus hemangiomas (CSHs) are extraaxial vascular malformations that tend to bleed during surgery.

METHODS

We reviewed 12 magnetic resonance imaging scans with CSH, 5 of them biopsy proven.

RESULTS

In our review, CSH commonly presented as a lobulated mass with high, uniform signal intensity on T2-weighted images, a dumbbell shape, and a sellar extension. Two thirds presented a "filling-in" pattern of enhancement on dynamic imaging. These features should lead to a correct preoperative diagnosis, which is essential for surgical planning and avoiding hemorrhagic complications.

CONCLUSIONS

A combination of low signal on T1, high signal on T2 and fluid-attenuated inversion recovery, no diffusion restriction and homogenous enhancement should place CSH at the top of the list of differential diagnoses. This is especially true when there is a "filling-in" pattern on dynamic or delayed imaging. Doing so may alert surgeons to the possibility of copious intraoperative bleeding and therefore avoid complications of hemorrhage.

Bleomycin for Head and Neck Venolymphatic Malformations: A Systematic Review

BACKGROUND

Venolymphatic malformations are rare benign vascular lesions of the head and neck. Sclerotherapy has become the first-line therapy of these lesions with bleomycin being a sclerosing agent commonly used.

PURPOSE

To perform a systematic review of the published literature to synthesize evidence on the safety and efficacy of bleomycin for the treatment of head and neck venolymphatic malformations.

DATA SOURCES

A systematic review of the literature (January 1995-May 2019) was performed in PubMed, Embase, and Cochrane Library databases to identify studies on sclerotherapy of venolymphatic malformations of the head and neck.

STUDY SELECTION

A total of 32 studies with participants met the inclusion criteria among which 1121 patients were included in the systematic review.

DATA ANALYSIS

Two reviewers independently screened and extracted data and assessed the risk of bias. The primary outcome was the subjective or objective reduction of lesion size as well as minor and major complications.

DATA SYNTHESIS

The bleomycin/pingyangmycin sclerotherapy achieved subjective or objective lesion size reduction in 96.3% (95% CI 94.1%-98.5%) of patients. Minor complications were observed in 16.2% and major complications in 1.1%.

CONCLUSION

Bleomycin is a highly effective treatment of venolymphatic malformations of the head and neck with a low rate of major adverse events. This study represents an update on the "available" evidence, but only low-to-moderate quality studies were available.

LIMITATIONS

This study reviewed 32 studies performed in different parts of the world, but there was heterogeneity of the study designs and interventions.

Localized intravascular coagulation in venous malformations: A system review

Venous malformation is one of the slow-flow vascular malformations. Dysfunction of coagulation often occurs in most venous malformations, especially the diffuse and multifocal lesions, referred to as localized intravascular coagulopathy. It is characterized by the elevation of D-dimers and fibrin degradation products, low levels of fibrinogen, FV, FVIII, FXIII, and antithrombin III, and sometimes minor-to-moderate thrombocytopenia. Here we reviewed the clinical manifestations, pathogenesis, diagnosis, and treatment of localized intravascular coagulopathy in venous malformations.

Role of ultrasound in diagnosis and differential diagnosis of deep infantile hemangioma and venous malformation

OBJECTIVE

For vascular anomalies, when clinical findings are not sufficient, auxiliary examination is essential. In this study, we characterize and differentiate the ultrasound (US) findings of deep infantile hemangioma (DIH) and venous malformation (VM).

METHODS

A total of 135 patients (140 lesions) with clinically proven DIH and VM were analyzed. The following US characteristics were assessed: size, shape, border, echogenicity, echotexture, vascularity, and lesion softness. One-way analysis of variance, nonparametric test, χ² test, Fisher exact test, and paired sample t-test were used to analyze the US results.

RESULTS

On gray-scale US images, DIH and VM were more common in subcutaneous soft tissue, but VM could invade the muscle. Most DIHs were expressed as hyperechoic structures (47.0%), had a well-defined border (74.2%), and were homogeneous (53%), whereas the majority of VMs showed mixed echoic with anechoic structures (87.8%), had an ill-defined border (58.1%), and were heterogeneous (100%). On color Doppler US, most DIHs (90.9%) showed high vascular density, whereas only a few blood flow signals were found in most VMs (98.6%). On elastic US, VM was softer than DIH (2.9 ± 0.8 vs 2.6 ± 0.5; P = .048). After DIH involution, the distance from the body surface increased (P = .015); the lesion's vertical diameter, peak arterial systolic velocity, and Vmax were significantly decreased (P = .006, P = .047, and P = .026, respectively). Also, early VM (<18 months) has the typical US performance of VM. Compared with elastic US, gray-scale and Doppler US provided stronger evidence for differential diagnosis.

CONCLUSIONS

DIH and VM have different US manifestations that can provide evidence for diagnosis and differential diagnosis of DIH and early VM.

Clinicoradiologic predictors of sclerotherapy response in low-flow vascular malformations

OBJECTIVE

To evaluate the clinical effectiveness of sclerotherapy agents in low-flow vascular malformations (LFVM) and identify clinical/imaging features to predict response.

METHODS

A retrospective analysis of hospital records of symptomatic LFVM patients who underwent phlebosclerotherapy from January 2015 to April 2018 was done. Patients were subdivided into venous malformations (VM) and lymphatic malformations (LM). Out of 246 cases, 223 patients (132 males, 91 females; age range, 2-52 years) had VM and 23 (13 males, 10 females; age range, 3 months to 45 years) had LM. The clinical response was graded as excellent (>60%), good (30%-60%), and poor (<30%). More than 30% was considered as acceptable response. The χ² test was performed for correlation between clinical response and clinical, sonographic, magnetic resonance imaging, phlebographic parameters followed by multilinear regression.

RESULTS

Cavitary (43%) and spongy (37.7%) were the most common phlebographic patterns seen among VM and a cavitary pattern (87%) was most frequent in LM. Sodium tetradecyl sulphate and bleomycin were most commonly used sclerosants in VM and LM, respectively. The mean number of sessions was 4.35 (range, 1-23) in VM and 2.64 (range, 2-7) in LM. Among VM, 114 patients (51.1%) had excellent response to treatment (>60%) and 75.8% patients had an acceptable response (>30%). All patients with LM had an acceptable response (excellent response in 86.9%). Clinical disfigurement, discoloration, diffuse involvement, dysplastic venous morphology on phlebogram, and late and indirect draining vein correlated with poor response to sclerotherapy in VM (P = .003, P = .036, P = .007, P = .008, P = .003, and P = .035, respectively). Cystic components on ultrasound examination and direct draining vein were seen more often in excellent responders (P = .004 and P = .007) in addition to absence of disfigurement, discoloration, and diffuse involvement (P = .032, P = .003, and P = .002). Mod els comprising clinical disfigurement, dysplastic veins, and late draining vein had the greatest predictive value for poor response (R² = 0.256). Also, the best model for predicting excellent response comprised presence of direct draining vein and absence of skin discoloration (R² = 0.109). Eleven instances of minor complications occurred among a total of 1032 sessions, seven with sodium tetradecyl sulphate and four with polidocanol.

CONCLUSIONS

Acceptable response to sclerotherapy was achieved in majority of LFVM with extremely low complication rates. Clinicoradiologic features, especially phlebographic findings, correlated with response to sclerotherapy.

Intramuscular venous malformations of the calf: Surgical treatment outcomes of 57 patients

OBJECTIVES

To report the outcomes of surgical treatment of calf intramuscular venous malformations (IMVMs) on pain, functional limitation, and quality of life.

METHODS

We retrospectively reviewed 57 consecutive patients who had surgery for IMVM of the posterior compartment of the leg between 2010 and 2015. Treatments were all done at a single institution.

RESULTS

Patients presented with pain (52), muscle contracture (14), or pulmonary embolism (4). Muscle involvement included the soleus muscle (n = 28, 49%), the gastrocnemius muscle (n = 25, 43%), and deep muscles (n = 4, 7%). Complete excision was possible in 52 patients (91%) and partial excision in 5 (9%). Thirty-five of 46 patients who had an MRI follow-up at six months had no residual venous malformation. At the final follow-up (mean 39 months), 32 of 40 patients seen had no residual pain and 37 had no residual functional impairment.

CONCLUSION

In cases where IMVM is located in one muscle in the leg, we demonstrated that surgery yielded improvement in pain, function, and quality of life.

Management of massive venous malformations by percutaneous injection of bleomycin combined with fibrin glue in the head and neck

PURPOSE

The aim of this study was to evaluate the effectiveness of percutaneous injection of bleomycin combined with fibrin glue in treating massive venous malformations (MVMs) in the head and neck region.

MATERIALS AND METHODS

A retrospective case series analysis of 22 patients who underwent percutaneous sclerotherapy between June 2015 and December 2018 was performed. All the patients were examined by comparing the size of the venous malformations (VMs) and their responses to treatment including complications in the follow-up.

RESULTS

The follow-up period ranged from 6 to 24 months. Ten patients (10/22) were completely cured and 10 patients (10/22) exhibited excellent size reduction of their VMs. Two patients (2/22) exhibited reasonable size reduction and were recommended to undergo a second sclerotherapy procedure. However, both patients were satisfied with the outcomes and refused subsequent treatment. Neither systemic nor local complications occurred in this study. All the patients were satisfied with their significant size reductions and symptom improvements without recurrences during follow-up.

CONCLUSION

Percutaneous injection of bleomycin combined with fibrin glue is a promising treatment option that yielded excellent size reduction with a low risk of complications on MVMs in the head and neck region.

Qualitative study of patients with venous malformations: symptom experiences and content validity of patient-reported outcome measures

PURPOSE

To determine important symptoms and functional effects of venous malformations (VMs) to assess the content validity of commonly used patient-reported outcome (PRO) measures for use with VM patients.

METHODS

This cross-sectional, qualitative study involved cognitive interviews with participants with VM aged ≥ 14 years. From February to June 2016, 11 participants (8 female) with a mean (± standard deviation) age of 31 ± 15 years were recruited from three clinical sites. The following subgroups were evaluated: 5 adults (aged ≥ 18) with trunk/extremity VMs; 3 adolescents (aged 14-17) with trunk/extremity VMs; and 3 adults with head/neck VMs. We evaluated the content validity of the Worst Pain Numeric Rating Scale (NRS), Patient-Reported Outcomes Measurement Information System (PROMIS®) Pain Interference 8-item short form, and PROMIS Physical Function 8-item short form.

RESULTS

The most common participant-reported VM symptoms were swelling (n = 10), skin discoloration (n = 8), acute episodic pain (n = 8), chronic pain (n = 7), numbness (n = 7), and tingling/burning (n = 6). Participants reported that VMs affected their physical function (n = 10), appearance (n = 10), relationships/social activities (n = 7), and emotional health (n = 3). The Worst Pain NRS and PROMIS Pain Interference measures were relevant to all participants' VM experience. Only adults with head/neck VMs found the PROMIS Physical Function measure to be irrelevant. The assessed PRO measures did not address several symptoms commonly reported by VM patients (swelling, skin discoloration, numbness, and appearance).

CONCLUSION

These results suggest that several VM symptoms are not assessed fully by commonly used PRO measures, and that the relevance of functional limitation questions may vary by VM location.

Sclerotherapy for Venous Malformations of Head and Neck: Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis of studies performing sclerotherapy for treatment of venous malformations (VMs) of the face, head and neck. It is our hope that data from this study could be used to better inform providers and patients regarding the benefits and risks of percutaneous sclerotherapy for treatment of face, head and neck VMs. We searched PubMed, MEDLINE, and EMBASE from 2000–2018 for studies evaluating the safety and efficacy of percutaneous sclerotherapy of neck, face and head VMs. Two independent reviewers selected studies and abstracted data. The primary outcomes were complete and partial resolution of the VM. Data were analyzed using random-effects meta-analysis. Thirty-seven studies reporting on 2,067 patients were included. The overall rate of complete cure following percutaneous sclerotherapy with any agent was 64.7% (95% confidence interval [CI], 57.4–72.0%). Sodium tetradecyl sulfate had the lowest complete cure rate at 55.5% (95% CI, 36.1–74.9%) while pingyangmycin had the highest cure rate at 82.9% (95% CI, 71.1–94.7%). Overall patient satisfaction rates were 91.0% (95% CI, 86.1–95.9%). Overall quality of life improvement was 78.9% (95% CI, 67.0–90.8%). Overall permanent morbidity/mortality was 0.8% (95% CI, 0.3–1.3%) with no cases of mortality. Our systematic review and meta-analysis of 37 studies and over 2,000 patients found that percutaneous sclerotherapy is a very safe and effective treatment modality for treatment of VMs of the head, neck and face.

Buccal vascular malformation with multiple giant phleboliths: a rare case presentation and review of the literature

PURPOSE

The purpose of this study was to describe a case and to review the diameters, symptoms, locations, and treatment methods for vascular malformations (VMs) with phleboliths. Our case report is probably the first to mention this observation because of sizes and large number of phleboliths in buccal region.

CASE PRESENTATION

A 26-year-old male patient was referred to Ordu University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery for the evaluation and management of a painless tender swelling in the left buccal region. Clinically, a bluish mucosal lesion of the posterior region of the left buccal mucosa and lip is apparent. Panoramic radiography and CT were obtained for radiographical examinations. Multiple giant phleboliths with the largest dimension of 32 mm were seen in this region. Left maxillary first molar teeth extraction was indicated. An aspiration was performed and revealed that there is a risk of severe hemorrhage. The patient did not want to take MRI and stated that he only wanted to have dental treatment. Therefore, it was decided that the maxillary first molar should be retained in the region and endodontic treatment should be done, if necessary.

CONCLUSIONS

The clinic of phlebolith patients is painless swelling and can reach up to 6 cm. The localization is not specific but is found in the masseter and parotid regions generally. Treatment may be invasive or non-invasive depending on, location, accessibility, depth of invasion, age, cosmetic issues, and risk of severe hemorrhage, as with the current case.

A Tie2 kinase mutation causing venous malformations increases phosphorylation rates and enhances cooperativity

The endothelial receptor tyrosine kinase Tie2 plays an important role in vascular formation and maintenance. Mutations in Tie2 lead to vascular malformations, which are painful vascular lesions that cause disfigurement, bleeding, and thrombosis. R849W Tie2 is the most common mutation implicated in an inherited form of vascular malformations and has been shown to be activating, though little is known about the kinetic features of catalysis. Here we undertake a steady-state kinetic analysis of heterologously expressed and purified wild type (WT) and R849W Tie2. While the catalytic efficiencies of the two forms are not significantly different, the observed maximal rate of phosphorylation, k_cat,obs, is > 3-fold higher for R849W Tie2 compared to WT. Notably, steady-state catalysis by R849W Tie2 has more striking sigmoidal features compared to WT, suggesting enhanced positive cooperativity. We propose that activating catalytic features are one important consequence of the R849W mutation, though likely other factors such as increased protein binding affinity also contribute to the phenotypes observed in patients.

Eruption of a venous malformation through an iliac bone harvesting site after trauma

Harvesting grafts from the anterior iliac bone has been associated with various complications. A 50-year-old woman presented to our department with a chief complaint of right inguinal swelling and pain. Autologous bone grafts had been harvested on two previous occasions from the right anterior iliac crest for use in the reconstruction of multiple facial fractures. Computed tomography and magnetic resonance imaging revealed a full-thickness bone defect in the right anterior iliac crest. A mass was noted in the right gluteus minimus, while a multilocular cystic mass extended from the right iliac crest defect to the right inguinal region. Both the inguinal mass and gluteal mass were removed under general anesthesia. Following histopathological analysis, the gluteal mass was diagnosed as a venous malformation(VM). Based on the patient’s clinical course, iliac bone graft harvesting and trauma to the gluteal region triggered hemorrhaging from the VM. Blood components leaked out from the fragile portion of the iliac bone defect, forming a cystic lesion that developed into the inguinal mass. In this case, a coincidental VM resulted in a rare complication of iliac bone graft harvesting. These sequelae could have been avoided by planning for more appropriate ways to collect the grafts.

Quality of life after endovascular sclerotherapy of low-flow venous malformations: the efficacy of polidocanol compared with ethanol

Background Limited information is available on mid-term results and quality of life (QOL) after endovascular sclerotherapy of venous malformations. Purpose To compare two agents-polidocanol and ethanol-with a focus on the influence on QOL after sclerotherapy. Material and Methods Forty-one consecutive patients with a venous malformation in the head and neck area or in the extremities were treated with polidocanol between 2008 and 2013. Pre- and post-treatment magnetic resonance imaging (MRI) scans were compared. All patients completed a self-evaluation form on symptoms as well as a QOL questionnaire. The results were compared with previously obtained material during 1991-2001, comprising 44 consecutive, similarly located venous malformation patients subject to ethanol sclerotherapy. Results No significant clinical complications were observed. Subjectively, 19 (46%) of the patients benefitted from the treatment. QOL results showed that 85% of patients had an index < 39 - where 0 represents the highest and 100 the lowest QOL. Patients in the ethanol group had marginally better overall post-treatment QOL results. Post-treatment MRI in 35 patients showed the size of the malformation unchanged in 19 (54%) patients, in ten (29%) there was a decrease (<50%) while in six (17%) the decrease was more significant (>50%). Post-treatment MRI results did not correlate with either subjective symptoms or QOL results. Conclusion Polidocanol sclerotherapy were found to be an effective, safe, and well tolerated treatment option for low flow venous malformations. Routine MRI for follow-up appears redundant and may be omitted.

Image guided sclerotherapy for the treatment of venous malformations

Background

Percutaneous sclerotherapy is the preferred method of treatment for VMs (venous malformations). However, treatment protocols vary, and research on the most effective sclerosant is conflicting. Additionally, there is limited knowledge on the effect of sclerosant volume on treatment outcome. This study aims to determine the outcomes and complications of image-guided sclerotherapy for VMs with respect to sclerosant and sclerosant volume. Towards this, a 10-year retrospective chart review was conducted of patients with VMs treated with sclerotherapy at the Vascular Anomalies Clinic at British Columbia Children’s Hospital.

Results

Thirty-four patients with VMs were treated of which 15 had a successful outcome, 13 had a failed outcome, and 6 had additional planned treatments after the study time period. Lesions on the head and neck or classified as type I or II had the highest success rates. Combination therapy with both ethanol and 3% STS (sodium tetradecyl sulphate), and ethanol alone had a higher success rate (64% and 60%) compared to 3% STS (11%). Major complications were most associated with 3% STS (17%) followed by ethanol (9%), and no major complications were found with combination. No relationship between the volume of sclerosant per lesion volume and outcome was found.

Conclusions

Combination and ethanol were the most effective sclerosants in terms of highest success rates and lowest complication rates, and sclerosant volume per lesion volume had no effect on outcomes. Future work should aim at studying larger sample sizes to account for the multiple factors that may influence the choice of sclerosant and treatment outcomes.

Treatment of voluminous and complicated superficial slow-flow vascular malformations with sirolimus (PERFORMUS): protocol for a multicenter phase 2 trial with a randomized observational-phase design

BACKGROUND

Slow-flow superficial vascular malformations (VMs) are rare congenital anomalies that can be responsible for pain and functional impairment. Currently, we have no guidelines for their management, which can involve physical bandages, sclerotherapy, surgery, anti-inflammatory or anti-coagulation drugs or no treatment. The natural history is progressive and worsening. Mammalian target of rapamycin (mTOR) is a serine/threonine kinase that acts as a master switch in cell proliferation, apoptosis, metabolism and angio/lymphangiogenesis. Sirolimus directly inhibits the mTOR pathway, thereby inhibiting cell proliferation and angio/lymphangiogenesis. Case reports and series have reported successful use of sirolimus in children with different types of vascular anomalies, with heterogeneous outcomes.

OBJECTIVE

The objective of this trial is to evaluate the efficacy and safety of sirolimus in children with complicated superficial slow-flow VMs.

METHODS/DESIGN

This French multicenter randomized observational-phase, phase 2 trial aims to include 50 pediatric patients 6 to 18 years old who have slow-flow (lymphatic, venous or lymphatico-venous) voluminous complicated superficial VM. Patients will be followed up for 12 months. All patients will start with an observational period (no treatment). Then at a time randomly selected between month 4 and month 8, they will switch to the experimental period (switch time), when they will receive sirolimus until month 12. Each child will undergo MRI 3 times: at baseline, at the switch time, and at month 12. For both periods (observational and treatment), we will calculate the relative change in volume of the VM divided by the study period duration. This relative change weighted by the study period duration will constitute the primary endpoint. VM will be measured by MRI images, which will be centralized and interpreted by the same radiologist who will be blinded to the study period. Hence, each patient will be his/her own control. Secondary outcomes will include assessment of safety and efficacy by viewing standardized digital photographs and according to the physician, the patient or proxy; impact on quality of life; and evolution of biological makers (coagulation factors, vascular endothelial growth factor, tissue factor).

DISCUSSION

The main benefit of the study will be to resolve uncertainty concerning the efficacy of sirolimus in reducing the volume of VMs and limiting related complications and the safety of the drug in children with slow-flow VMs. This trial design is interesting in these rare conditions because all included patients will have the opportunity to receive the drug and the physician can maintain it after the end of the protocol if is found efficient (which would not be the case in a classical cross-over study).

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02509468 , first received: 28 July 2015. EU Clinical Trials Register EudraCT Number: 2015-001096-43.

Patient-Reported Outcomes of Bleomycin Sclerotherapy for Low-Flow Vascular Malformations and Predictors of Improvement

Purpose

There is paucity of data on patient-perceived outcomes of bleomycin sclerotherapy for low-flow vascular malformations. In this study, the long-term outcomes of bleomycin sclerotherapy were investigated in terms of quality of life (QoL) and patient-perceived changes in health.

Materials and Methods

A cohort of Dutch patients with vascular malformations treated with bleomycin sclerotherapy (June 2010-November 2015) completed a questionnaire evaluating disease symptoms, QoL (Short Form 36), patient-perceived change in health status (Global Rating of Change scales) and treatment satisfaction. QoL was assessed for the patient’s status before and after treatment and was analyzed relative to an age and sex-matched Dutch reference population. Predictive factors associated with QoL and patient-perceived improvement in overall health status were assessed using multivariable linear and logistic regression analyses, respectively.

Results

Seventy-seven patients, with a median follow-up of 22 months, were enrolled. About half of the respondents (49.3%) indicated that they perceived (any form of) improvement in their overall health status. Most often improved were the specific health aspects ‘pain’ (54.5%) and ‘overall severity of symptoms’ (57.1%). No factors were significantly predictive for patient-perceived improvement in health with respect to the vascular malformation. Impairment in work- or study-related activities prior to sclerotherapy was found to negatively impact physical QoL at follow-up (p = 0.03).

Conclusion

Approximately half of patients with low-flow vascular malformations indicate an improvement in overall health status following bleomycin sclerotherapy, particularly concerning pain and severity of symptoms. However, most patients only perceived little to moderate improvement to their health and desire further treatment.

Intramuscular Venous Malformations of the Upper and Lower Limbs: Indications and Outcomes of Sclerotherapy

PURPOSE

Multiple treatment options have been described for intramuscular venous malformations (VMs) of the limbs. At the current time, there are no clear management guidelines. The aim was to evaluate efficacy and safety of sclerotherapy in this type of VMs.

MATERIALS AND METHODS

This is a single-center, retrospective review of patients treated for extremity intramuscular VMs between January 2013 and June 2017. The primary outcomes were the improvement of symptoms self-assessed by questionnaires, and the reduction in VM size measured by magnetic resonance (MRI).

RESULTS

Sclerotherapy was performed in 81 patients with extremity intramuscular VMs. The sclerosing agent was ethanol in 46 cases (56.8%), polidocanol in 27 cases (33.3%), a combination of both in 8 cases (9.9%). The mean follow-up was 26 months (range 3-52). Overall quality of life was improved in 62 patients (76.5%). The postoperative MRI showed a minimum change of VM size in 68 patients (83.9%). A major complication (peripheral nerve injury) was observed in 1 case (1.2% of patients, 0.5% of procedures). Minor complications occurred in 9 cases (11.1% of patients, 4.1% of procedures).

CONCLUSIONS

Sclerotherapy is a low-invasive, effective and safe treatment for intramuscular VMs of the extremities. It induces a significant improvement in symptoms, also when the VM size is unchanged.

LEVEL OF EVIDENCE

Level 4, Case Series.

[Effect of foam sclerotherapy for the treatment of oropharyngeal venous malformation]

Objective: To evaluate the safety and efficacy of foam sclerotherapy with polidocanol for the treatment of venous malformation in the oropharynx. Methods: The clinical data of 21 children with venous malformation in the oropharynx treated by foam sclerotherapy were retrospectively analyzed. There were 10 males and 11 females, ranging in age from 1 month to 13 years, with a median age of 2.3 years. MRI was performed in all children, and the diagnosis was further confirmed by radiography. After general anesthesia, the oropharynx was exposed by opening device. Scalp acupuncture was used to pucture lesions and polidocanol foam was injected after the nidus was confirmed by digital subtraction angiography(DSA). The follow-up time ranged from 2-29 months, with a mean time of 15 months. The clinical symptoms, imaging data, therapeutic effects and postoperative complications were evaluated. Results: Total numbers of treatment were 52 times, 1-6 times/case; 13 cases were cured, 7 cases was relieved and no response in one case. Postoperative swelling in 13 cases, fever in 3 cases, local mucosal ulcer in 2 cases, difficult extubation in 2 cases. No nerve injury, swallowing function damage and cardiopulmonary accidents were found in all patients. Conclusion: Foam sclerotherapy with polidocanol in the treatment of venous malformation in the oropharynx is a safe and effective method.

[Vascular anomalies. Part II: vascular malformations]

Vascular malformations are congenital vascular anomalies with normal endothelial turnover, which can affect the whole vessel tree (arterial, capillary or lymphatic) both as isolated defects or as part of a syndrome. Developmental errors during embryogenesis, such as abnormal signaling processes that control the apoptosis, maturation and growth of vascular cells, lead to the persistence of vascular plexus cells with some degree of differentiation. Vascular malformations are usually present at birth, although symptoms or complications may be manifested later. Since the overwhelming majority are symptomatic, treatment is indicated which is often aimed only at improving the symptoms by controlling the size.

Venous malformations management by Er,Cr:YSGG laser: An Alternative approach

BACKGROUND AND AIM

Venous malformations (VMs) are slow-flow vascular anomalies composed of ectatic venous channels. Its management with Er,Cr:YSGG laser has been proven effective. In the present case a teenage patient reported with a bluish lesion, soft inconsistency on the dorsal aspect of tongue. The lesion was removed with Er, Cr: YSGG laser (2780 nm) with minimal anaesthetic infiltration.

RESULTS

Patient reported no postoperative pain. Clinical follow up after three months showed excellent results and uneventful healing.

CONCLUSION

Er,Cr:YSGG laser showed high clinical safety. Its advantages resulted in excellent healing of lesion and better acceptance by patient.

CT-Guided Percutaneous Sclerotherapy for Low-Flow Retrobulbar Intraconal Venous Malformations

BACKGROUND AND AIMS

Until now, no study has focused exclusively on low-flow retrobulbar intraconal venous malformations (RIVMs) which may require treatment due to cosmetic defect, pain, and visual dysfunction. The treatment for RIVMs which surround the optic nerve remains challenging. This case series aimed to evaluate the technical feasibility, effectiveness, and safety of percutaneous sclerotherapy with polidocanol for low-flow RIVMs, using local anesthesia.

METHOD

This is a prospective, non-comparative, single-center, interventional case series. All patients signed informed consent forms. Seven patients with RIVMs were treated with percutaneous sclerotherapy with polidocanol/air foam using CT guidance. Primary endpoints are reduction in the volume of RIVMs and pain relief assessed by visual analog scale (VAS). Secondary endpoints are exophthalmos and recording adverse events obtained in clinical follow-up during outpatient visits.

RESULTS

Results revealed that the mean volume of RIVMs was decreased from 12.05 ± 6.35 cm³ preoperatively to 1.56 ± 0.43 cm³ postoperatively, (p = 0.005), with a mean decrease of 87.05%. The intraocular pressure was decreased from 14.19 ± 2.99 to 11.79 ± 1.25 mmHg, (p = 0.043). The mean VAS score was decreased from 3.43 ± 2.37 preoperatively to 1.29 ± 0.76 postoperatively, (p = 0.023). The exophthalmos score was decreased from 1.75 ± 0.27 to 1.34 ± 0.31 cm, (p = 0.005). All patients were satisfied with the treatment, which did not leave a postoperative scar.

CONCLUSIONS

The results of percutaneous intralesion injection of polidocanol for RIVMs are encouraging. The present results suggest that this method could be a safe and effective treatment option for patients with RIVMs.

[Vascular medicine and foam sclerotherapy for venous malformations]

Vascular medicine plays a determining role in the management of vascular malformation, especially venous malformations. Ideally, therapeutic decision should be made in a multidisciplinary staff meeting. Vascular medicine plays the leading role for diagnosis and duplex-Doppler evaluation of coagulation disorders, potentially associated with an assessment of treatment feasibility using chemical or thermic endovascular techniques. Potential adherence of compression therapy must also be evaluated. Decision trees often mention sclerotherapy for the management of venous malformations. Echo-guided foam sclerotherapy is preferred. The superiority of foam sclerotherapy over liquid sclerotherapy has been demonstrated. Indications and limitations of this specific treatment remain to be definitively determined, especially for treatments with radiological control. Side effects are now well described for the use of foam sclerotherapy for venous malformations. They remain limited. Future developments should help optimize the sclerosing effect of currently used foams or other products to be developed. For the vascular medicine specialist, the main contribution is to define the appropriate use of echo-guided sclerotherapy.

Painless swollen calf muscles of a 75-year-old patient caused by bilateral venous malformations

A 75-year-old man presented with knee pain due to medial osteoarthritis of the knee in the orthopedic outpatient clinic. Conservative treatment was started with steroid infiltration. Besides his knee complaint reported a bilateral painless swollen calf muscle without traumatic cause, and also without any pain at night, fever or medical illness. On physical examination the soleus muscle had a swollen aspect in both calfs. The skin appeared normal without deformities and the arterial pulsations were intact. An X-ray did not show abnormalities in the tibia. Magnetic resonance imaging of the legs revealed bilateral multiple saccular intramuscular venous malformations involving the soleus muscle. Intramuscular venous malformations in skeletal muscles are rare, especially when the occurrence is bilateral. Bilateral venous malformations have the potential to be missed because of the intramuscular localization. Symptoms of intramuscular venous malformation can be often mild and overlap with non-exercise related compartment syndrome, claudication, lymphedema and post thrombotic syndrome or muscle strains.

Venous malformations of the head and neck: current concepts in management

Low-flow venous malformations are congenital lesions and they are the third most common vascular anomaly in the head and neck. In this paper, the third in a series of three educational reviews, we discuss current trends in their management, and include a summary of common sclerosant agents used in their control.

A modified Tessari method for producing more foam

This study aimed to develop a modified Tessari method for producing more sclerosing foam in treatment of extensive venous malformations. Sclerosing foam was produced by using Tessari method and the modified Tessari method. The procedure of the later was as follows: prepared foam in a sclerosant–air ratio of 1:4; connected three disposable 10 ml syringes to two medical three-way taps; drawn 4 ml of liquid sclerosant into one syringe and 16 ml averagely of air into the other two; then moved the plungers of all syringes back and forth for 20 times to produce sclerosing foam. The volume and foam half time (FHT) of foam produced by the two methods were compared. The average volume of sclerosing foam produced by Tessari method and the modified Tessari method were 9.8 and 19.7 ml, and assessed to have statistical difference. The FHT of foam produced by the two methods were 120 and 150 s, and assessed to have statistical difference. In conclusion, the modified Tessari method could produce more fresh and stable sclerosing foam.