KTWS (Klippel-Trenaunay-Weber syndrome): A systematic presentation of a rare disease

BACKGROUND

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare disease with a wide range of manifestations. KTWS is characterized by a clinical triad of varicosities of the extremities, cutaneous vascular malformations, and hypertrophy of soft tissues and long bones. The diagnosis is made clinically supplemented with magnetic resonance imaging and computed tomography.

AIM

Hereby we aim to highlight the significance of the possible life-threatening first-time presentations associated with the GI system in previously undiagnosed KTWS patients.

PATIENT

We report the case of a 47-year-old male with KTWS, who presented with various symptoms such as rectorrhagia since childhood, digestive problems and abnormal lateral vascular malformations of the left buttock which extended all the way to the leg, vascular malformations of the left fourth and fifth toes as well as soft tissue swelling of the left foot. There was no evidence of other clinical presentations. The patient was hospitalized with severe rectorrhagia and a hemoglobin level of 3/9. Physical examination revealed a blood pressure of 85/55 and pulse rate of 115. Ruptured aneurysm of the superior mesenteric artery was found on angiography and subsequently treated with embolization. Dermatologic evaluation showed pitting edema of the left leg and foot and multiple vascular lesions. Thus a diagnosis of KTWS was established. Pulsed dye laser therapy and compression bandage was performed for the patient. The patient's follow-up was done 3 months after discharge for which the patient was again consulted by a dermatologist and gastroenterologist. Lymphedema of the left leg had improved to a great extend so treatment with compression bandage was continued. Colonoscopy was repeated for the patient to evaluate and control possible active sources of bleeding, due to potential life-threating complications.

RESULTS

According to previous findings, there have been few case reports of KTWS presenting with gastrointestinal manifestations, fewer of which have covered acute life-threatening bleedings associated with this system.

Klippel-Trenaunay syndrome and pregnancy: A Case-Report

Klippel-Trenaunay Syndrome is a benign disease with a low incidence rate. Pregnant women with KTS may be at increased risk of thrombosis and coagulopathy due to normal hemodynamic changes during pregnancy. The choice of delivery route for KTS pregnant woman needs rigorous evaluation. This study reported a case of successful delivery by oxytocin combined with balloon catheter induction for the first time, providing more options for KTS pregnant woman. At the same time, this study reported a successful case of labor induced by oxytocin combined with balloon catheter for the first time, which further explored the obstetric management of pregnant women with KTS and provided them with more delivery options.

Overgrowth syndromes and new therapies

Overgrowth syndromes represent a diverse group of disorders with overlapping features. Interdisciplinary management by a team of experts in vascular anomalies is crucial for establishing the correct diagnosis and optimizing outcomes for these patients. Unique management considerations include increased risk for thrombosis and in some cases, cancer. In recent years, research has demonstrated that these disorders are primarily caused by somatic mutations in growth pathways, particularly the PI3K-mTOR pathway. This improved understanding had led to promising new therapies for this group of patients.

Patients with Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome is the most frequent systemic venous angiodysplasia. It is characterized by cutaneous capillary malformations - naevus flammeus, excessive growth of soft and bone tissue, venous and lymphatic malformations. Investigative methods include: clinical examinations, venography as the evidence of dysplastic changes of superficial and / or deep venous system, the Moyne obstruction and venous insufficiency perforator. Treatment is conservative, related to that of chronic venous disease. The surgery is aimed at removing the varices and insufficient perforators (Fig. 9, Ref. 8).

[Vascular anomalies]

Vascular anomalies are rare conditions that could be observed at all ages. They are classified, according to their histology, in vascular tumors or vascular malformations. The general practitioner plays a significant role in diagnosis and patient management, diagnosis being suspected on clinical history. In case of vascular anomaly, ultrasound-Doppler assessment is helpful to characterize morphologic and hemodynamic changes of the lesion and permits to monitor the evolution and to detect complications. Further investigations are often necessary prior to multidisciplinary management. In this article, a brief overview of vascular anomalies, their multidisciplinary management and the exemple of Klippel-Trenaunay syndrome are presented.

Klippel-Trenaunay syndrome in combination with congenital dislocation of the hip

Klippel-Trenaunay syndrome (KTS) is a rare and sporadic disorder characterized by the triad of capillary malformations, venous varicosities, and limb hypertrophy. The clinical manifestations of KTS are heterogeneous. In this report, we present a unique case of KTS in combination with congenital dislocation of the hip (CDH) in a 4-day-old female neonate. The patient had a widespread port-wine stain surrounded by regions of unaffected skin in a mosaic pattern, cutaneous hemangioma on the upper lip, left-sided hemihypertrophy involving the entire body, and also evidence of left CDH (based on the results of a physical examination and radiographic interpretation). We present this case for the rarity of presentation, discuss the relationship between KTS and CDH, and the treatment options available with a brief review of the literature.

[Clinical application of transcatheter embolization for Klippel-Trenaunay syndrome]

OBJECTIVE

To explore the feasibility of interventional treatment of Klippel-Trenaunay syndrome(KTS).

METHODS

The clinical data of 20 KTS patients admitted into our hospital from March 2005 to October 2010 were retrospectively analyzed.

RESULTS

All 20 patients underwent angiography after the relevant examinations. Among them, 18 patients underwent interventional treatment (embolization with PVA particles and spring coils). Two patients received no interventional treatment due to non-cooperation, high risk or extremely thin vessels. And 18 patients achieved excellent results after interventional treatment. Neither complications nor peri-operative mortality occurred. The patients were followed-up for an average period of 12 months. Mild symptoms recurred in 2 patients.

CONCLUSION

Interventional treatment is an effective, safe and mini-invasive procedure for KTS with satisfactory long-term outcomes.

[Multidisciplinary management of angiomas]

Angiomas are heterogenous vascular abnormalities, in terms of anatomy, biology and clinical course. Patients and families are often emotionally concerned. For all these reasons, a multidisciplinary approach is necessary in order to structure diagnostic and therapeutic work-up, and to ensure proper advice. The present paper summarizes contemporary classification of angiomas and presents some principles of multidisciplinary approach as it is applied for the past fifteen years at the University Hospitals of Geneva.

Efficacy and Safety of Microfoam Sclerotherapy in a Patient With Klippel-Trenaunay Syndrome and a Patent Foramen Ovale

BACKGROUND

Sclerotherapy with polidocanol microfoam injection under duplex guidance is a new treatment for venous malformations associated with Klippel-Trenaunay syndrome. Multidetector-row computed tomography (MDCT) venography is extremely helpful in the assessment of disease extension and the planning of therapy. Observation In this particular case, MDCT venography demonstrated the origin, course, and relationship to adjacent anatomical structures of aberrant vessels that configure the superficial venous system with an anatomically normal and patent deep venous system. At the end of the treatment, which consisted of 8 sessions of microfoam sclerotherapy within 12 months, a considerable reduction in the number and size of the percutaneously treated aberrant veins was observed. The obvious clinical improvement was objectively demonstrated with MDCT venography, which showed clear reduction in the number and size of treated veins. Further clinical investigation performed because of isolated migraine episodes related to the sclerotherapy session revealed that the patient had a patent foramen ovale. A transcranial Doppler examination during the procedure showed middle cerebral artery bubbles, which indicated right-to-left shunt. No cerebral damage was observed in a subsequent diffusion-weighted magnetic resonance examination.

CONCLUSIONS

Microfoam sclerotherapy is an effective treatment option in patients with Klippel-Trenaunay syndrome. MDCT venography allows diagnosis of the disease, planning of therapy, and assessment of response to treatment. Although foam-induced microembolism is a common phenomenon during sclerotherapy, in this report we demonstrate that polidocanol microfoam prepared with a low-nitrogen gas mixture is safe in a patient with a patent foramen ovale.

[Obstetric management of Klippel-Trenaunay syndrome. A case report]

A rare case of pregnancy in a patient with Klippel-Trenaunay-Weber syndrome is described. The arterio-venous anomalies in this patient originally occurred in her left leg. Her pregnancy was uneventful. A Cesarean section was performed at term. There were no signs of intravascular coagulation or cardiac decompensation. Prophylactic anticoagulant treatment was given during the 3rd trimester and into the early puerperium The clinical course and the risks of a pregnancy with this condition are discussed.

CONCLUSION

Klippel-Trenaunay syndrome was once thought to be a contraindication to pregnancy. With careful management, successful pregnancies can be achieved.

Urogenital involvement in the Klippel-Trenaunay-Weber syndrome. Treatment options and results

OBJECTIVE

Klippel-Trenaunay-Weber syndrome (KTWS) is a congenital condition characterized by vascular malformations of the capillary, venous and lymphatic systems associated to soft tissue and bone hypertrophy in the affected areas. This syndrome may involve bladder, kidney, urethra, ureter and genitals. We report the treatment of 7 KTWS patients with urogenital involvement.

MATERIALS AND METHODS

From 1995 to 2005, 7 patients with KTWS were evaluated and the charts of these patients were reviewed.

RESULTS

Patients' median age was 19-years (range 4 to 46-years) and only 1 was female. The clinical presentation included genital deformities in 3 cases, hematuria in 2 and urethrorragia in 2, one of which associated with cryptorchidism and phimosis. Three patients had an association of pelvic and genital malformations, including 2 patients with hematuria due to vesical lesions and 1 patient with left ureterohydronephrosis due to a pelvic mass. Two patients had urethral lesions. Treatment included endoscopic laser coagulation for 1 patient with recurrent hematuria and 1 patient with urethrorrhagia, pelvic radiotherapy for 1 patient with hematuria and circumcision in 2 patients with genital deformities. One patient required placement of a double-J catheter to relieve obstruction. Hematuria and urethrorragia were safely and effectively controlled with laser applications. Circumcision was also effective. The patient treated with radiotherapy developed a contracted bladder and required a continent urinary diversion.

CONCLUSIONS

Urogenital involvement in patients with KTWS is not rare and must be suspected in the presence of hematuria or significant cutaneous deformity of the external genitalia. Surgical treatment may be warranted in selected cases.

Vascular malformations. Part II: associated syndromes

Cutaneous vascular malformations are rare disorders representing errors in vascular development. These lesions occur much less commonly but are often confused with the common infantile hemangioma. It is important to properly diagnose vascular malformations because of their distinct differences in morbidity, prognosis and treatment. Vascular malformations may be associated with underlying disease or systemic anomalies. Several of these syndromes are well defined and can often be distinguished on the basis of the flow characteristics of the associated vascular malformation.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be able to better recognize underlying diseases or systemic anomalies that may be associated with vascular malformations. Participants should also better understand the various syndromes and conditions discussed and become more familiar with their management.

Ultrasound-guided foam sclerotherapy in patients with Klippel-Trenaunay syndrome

BACKGROUND

Klippel-Trenaunay syndrome, a congenital disorder, is characterized by capillary malformation, varicosities and bony or soft tissue hypertrophy. Since there is no cure for this disorder, treatment is directed towards secondary prevention of venous hypertension and preservation of functional integrity of the legs. Elastic stockings are the mainstay of treatment and are indicated in all cases. Surgery is reserved only for a few selected symptomatic patients, however the outcome is unsatisfactory in most cases, with recurrent pain, edema, poor cosmetic result and limb deformity. Ultrasound-guided foam sclerotherapy is a recently introduced minimally invasive ambulatory procedure for the treatment of chronic venous insufficiency. It was recently introduced to treat this disorder.

OBJECTIVES

To evaluate the efficacy of USFS in the treatment of patients with Klippel-Trenaunay syndrome.

METHODS

Seven patients diagnosed with Klippel-Trenaunay, with massive lower extremity involvement, were treated with USFS between October 2003 and October 2005. Sclerovein (polidocanol, Resinag, Switzerland) 2-4% was used as the sclerosant. The signs, symptoms and overall patient satisfaction were assessed before, during and after the treatment.

RESULTS

Patients' mean age was 26 years (range 15-54). The CEAP clinical classification, with ascending severity ranging from 0 (no signs) to 6 (active venous ulcer), was C4 in five patients (71.5%) and C5 and C6 in one patient each. The average number of sessions was 14.5 (range 9-21). No major complications were encountered. All seven patients reported improvement in signs and symptoms. Five of the 7 patients (71%) were very satisfied with the cosmetic result.

CONCLUSION

USFS is an effective minimally invasive ambulatory technique, essentially pain-free and with excellent short-term results in patients with Klippel-Trenaunay syndrome (when the deep system is functional). Long-term results and larger study groups are warranted.

[Minimally invasive surgical treatment of congenital vascular malformation]

The treatment of congenital vascular malformations is still a difficult problem. Minimally invasive surgical treatments such as sclerotherapy, embolizations, and laser treatments have become increasingly applied. Arteriovenous malformations are treated by transcatheter endovascular selective arterial embolizations, venous malformations by sclerotherapy, Nd: YAG laser, and DIOMED laser treatments, and Klippel-Trenaunay syndrome by endovenous DIOMED laser treatments. Most patients with congenital vascular malformations obtain good clinical outcomes after minimally invasive surgeries, although their long-term efficacy requires further investigation.

Klippel-Trenaunay syndrome: a multisystem disorder possibly resulting from a pathogenic gene for vascular and tissue overgrowth

Klippel-Trenaunay syndrome is characterized by a triad of varicose veins, cutaneous capillary malformation, and hypertrophy of bone and soft tissue. Appropriate evaluation and treatment of children displaying features of the disease may minimize morbidity. The clinical appearance, etiology, genetics, diagnostics, and treatment of Klippel-Trenaunay syndrome are herein explored.

New techniques for the evaluation and therapeutic planning of patients with Klippel-Trénaunay syndrome

BACKGROUND

Klippel-Trénaunay syndrome (KTS) is a well-known eponym for a capillary-lymphatic-venous malformation which is associated with soft tissue and skeletal hypertrophy, usually of one or more limbs. Plain films, sonograms, conventional venograms, and arteriograms have been employed for the evaluation of the disease.

OBJECTIVE

To demonstrate the usefulness of multidetector computed tomography (MDCT) and fast 3-dimensional magnetic resonance imaging (3D-MR) venography for the assessment and therapeutic planning of patients with KTS.

METHODS

A prospective study in 16 consecutive patients with KTS using MDCT and 3D-MR venography, performed between January 2004 and January 2006 in a university hospital in Pamplona, Spain.

RESULTS

In nearly all patients, persistent embryologic veins were observed, and in one subject aplasia/atresia of the whole deep venous system of the affected extremity was seen. In four individuals hypoplasia of the femoral vein was observed; one subject had duplication of the femoral vein, and in three patients aplasia/atresia of this vein was found. Only half of the patients had normal popliteal veins. In one patient, aneurysmal dilatation of the popliteal vein was detected, and in six subjects, aplasia of this vein was observed. The presence of geographic stains was suggestive of hypoplasia and/or aplasia of femoral and popliteal veins.

LIMITATIONS

The small size of the group of patients with KTS, which is related to low incidence of the disease.

CONCLUSIONS

MDCT and 3D-MR venography are extremely helpful for the global evaluation of patients with KTS. Information regarding soft tissue and bony anatomy as well as information about superficial and deep venous systems may be obtained with a single exam.

Klippel-Trenaunay-Weber syndrome and intramedullary cervical cavernoma: a very rare association. Case report

BACKGROUND

Klippel-Trenaunay-Weber syndrome is a rare mesodermal phakomatosis characterized by cutaneous hemangiomata, venous varicosities, and osseous-soft tissue hypertrophy of the affected limb. As the pathologic aspect of KTWS arises from the site in which malformations occur, the clinical picture varies widely from patients who complain for cosmetic reasons to patients with life-threatening lesions.

CASE DESCRIPTION

We describe a very rare case in which KTWS was associated with a cervical intramedullary cavernous angioma surgically treated.

CONCLUSION

This report confirms the wide range of expression of vascular abnormalities in neurocutaneous developmental diseases and the need of a careful multisystemic evaluation of these patients.

Evaluation and management of pain in patients with Klippel-Trenaunay syndrome: a review

Klippel-Trenaunay syndrome (KTS) is a rare disorder that consists of a triad of capillary vascular malformation, venous malformations and/or varicose veins, and soft tissue and/or bony hypertrophy. Pain is a real and debilitating problem in these patients. We have observed 9 common causes of pain in KTS: (1) chronic venous insufficiency, (2) cellulitis, (3) superficial thrombophlebitis, (4) deep vein thrombosis, (5) calcification of vascular malformations, (6) growing pains, (7) intraosseous vascular malformation, (8) arthritis, and (9) neuropathic pain. The management of pain in patients with KTS depends on its cause. These patients are best evaluated initially in a center with an experienced multidisciplinary team that includes a primary health care provider, surgeons, and ancillary staff. The ongoing care of a patient with KTS often depends on a local provider who is more readily accessible to the patient but may not have the expertise of a large center to manage the complications of KTS. The purpose of this communication is to review the common causes of pain in these patients to provide local health care providers and patients and their families with appropriate management strategies.

Klippel-Trenaunay syndrome and pregnancy

General recommendations on how to deal with pregnancy in patients with Klippel-Trenaunay syndrome (KTS) are rare. We describe the case of a 32-year-old female with KTS, involving the head and the left arm and leg, delivering a healthy female child, and are reviewing the recent literature. The risk to deliver an ill child is low in women with KTS. At the end of the 1st trimester a sonographic investigation can exclude angiodysplastic alterations of the fetus. If the fetus shows changes compatible with KTS, a termination can be discussed because the risk of fatal complications after delivery is high. During pregnancy the careful monitoring of coagulopathic disorders is necessary. Prior to delivery an MR-scan may be useful to detect angiodysplastic vascular structures next to the spinal cord, pelvic structures or the lower abdominal wall, which might complicate peridural anesthesia or caesarean section.

Klippel-Trenaunay syndrome

The association of three physical findings including capillary malformation, varicosities, and hypertrophy of bony and soft tissues corresponds to Klippel-Trenaunay syndrome. This triad of findings, described by the two French physicians Klippel and Trenaunay in 1900, differs from Parkes-Weber syndrome, in that Klippel-Trenaunay syndrome does not incorporate significant hemodynamic arteriovenous fistulas. Generally, management of this disease process should be individualized. Surgery should be considered in cases where skin ulcerations lead to persisting and recurrent bleeding, or where digital deformities lead to functional disabilities or where significant limb overgrowth leads to both functional and psychological impairment. Persistent hematochezia, hematuria, and vaginal and esophageal bleeding are considered indications for surgical intervention. Recurrent attacks of thrombophlebitis and cellulitis are treated medically with antiinflammatory agents and antibiotics. Otherwise, management of this syndrome is generally conservative, consisting of psychological encouragement, reassurance, and the continued use of graduated compressive stockings for varicosities and intermittent pneumatic compression pumps for lymphatic edema.

Congenital vascular lesions of the gastrointestinal tract: blue rubber bleb nevus and Klippel-Trenaunay syndromes

We present two cases of hemangiomatosis of the gastrointestinal tract. The first case describes a 59-year-old patient with upper gastrointestinal hemorrhage due to the blue rubber bleb nevus syndrome. The second case illustrates a 26-year-old patient with recurrent rectal bleeding due to Klippel-Trenaunay syndrome. These two syndromes are distinct disorders characterized by cavernous hemangiomas of the skin, soft-tissue, bones, and viscera. In addition, we review the available literature on the epidemiology, transmission, clinical features, associated conditions, diagnosis, and treatment of these two disorders.

[Klippel-Trenaunay syndrome: report of 3 new cases]

We report three new cases of Klippel-Trenaunay Syndrome (KTS), with differing evolution and involvement, in which the diagnostic criteria were confirmed by physical evaluation, imaging techniques, radiologic and laboratory studies. Vascular malformation and soft tissue hypertrophy were evident in all three patients: two showed internal lesions and bony hypertrophy and one patient showed digital deformities. We review the main features of this important angiodysplasia.

Klippel-Trénaunay syndrome. An unusual presentation of unilateral leg edema

Klippel-Trénaunay syndrome is a rare congenital condition that classically presents as a triad of varicosities, bone or soft-tissue hypertrophy, and cutaneous hemangiomas. The authors describe a case of this disease in an otherwise healthy patient with unilateral leg edema and intermittent bleeding from prominent ankle varicosities. The diagnosis was made on the basis of clinical presentation, diagnostic studies, and a comprehensive literature review. An overview of the pathology, treatment, and prognosis of this disease is provided.

Klippel-Trenaunay syndrome

Patients with Klippel-Trenaunay (KT) syndrome have a complex constellation of anomalies that includes cutaneous capillary malformation (usually on an affected limb), abnormal development of the deep and superficial veins, and limb asymmetry, usually enlargement. Mixed vascular malformations may be present and include capillary, venous, arterial, and lymphatic systems. The records of 79 patients referred for vascular anomalies were reviewed and 49 were found to have the three "cardinal" anomalies of KT syndrome. Twenty-six females and 23 males had 46 affected legs (27 right legs), 23 affected arms (15 right), 21 affected trunks, and 10 affected heads. Thirty-six had only one affected quadrant, 8 had two, and 5 had three or more. Although 40 patients had increased limb girth, measurable length discrepancy was noted in only 17 individuals. Patients were evaluated using a noninvasive imaging strategy including color duplex ultrasonography, MRI, lymphoscintigraphy, and plain radiographs. Treatment included compression, pulsed-dye laser treatment, reduction of arteriovenous malformations, and orthopedic procedures for overgrowth. All KT cases in this series occurred sporadically. We speculate that KT syndromes may be due to a somatic mutation for a factor critical to vasculogenesis and angiogenesis in embryonic development.

Klippel-Trénaunay syndrome: spectrum and management

OBJECTIVE

To describe a series of 252 patients with Klippel-Trénaunay syndrome (KTS), a rare congenital malformation characterized by the triad of capillary malformations, atypical varicosities or venous malformations, and bony or soft tissue hypertrophy usually affecting one extremity.

MATERIAL AND METHODS

We reviewed the clinical characteristics and findings in 136 female and 116 male patients with KTS who underwent assessment at Mayo Clinic Rochester between January 1956 and January 1995. In addition, management options are discussed.

RESULTS

Capillary malformations (port-wine stains) were found in 246 patients (98%), varicosities or venous malformations in 182 (72%), and limb hypertrophy in 170 (67%). All three features of KTS were present in 159 patients (63%), and 93 (37%) had two of the three features. Atypical veins, including lateral veins and persistent sciatic vein, occurred in 182 patients (72%). Operations performed in 145 patients with KTS included epiphysiodesis, stripping of varicose veins or venous malformations, excision of vascular malformations, amputations, and debulking procedures.

CONCLUSION

Most patients with KTS should be managed conservatively. The clearest indication for operation is a leg length discrepancy projected to exceed 2.0 cm at skeletal maturity, which can be treated with epiphysiodesis in the growing child. If a functioning deep vein system is present, removal of symptomatic varicosities or localized superficial venous malformations in selected patients can yield good results.

Klippel-Trénaunay syndrome: clinical features, complications, and management

Klippel-Trénaunay Syndrome (KTS) is rare and not well recognized among most physicians, which has lead to inappropriate management and delayed referral in many cases. Presented herein is the largest series ever reported from a single center in Saudi Arabia, comprised of 18 patients seen between 1990 and 1996, whose clinical features, complications, and management are discussed. All 18 patients had large angiomatous navei, hypertrophy of the soft tissue with bone overgrowth in the lower limbs, and extensive lower limb varicosities, which extended to the buttocks and lower abdomen in 2 patients. There were 4 patients who had undergone at least one operation for lower limb varicose veins prior to referral. The diagnostic workup and treatment for KTS is discussed in detail. It is essential that physicians understand how this complex syndrome presents, and the most appropriate means of investigating and managing it, to avoid unnecessary surgery being performed prior to referral to a specialist center.

Klippel-Trenaunay-Weber syndrome

The Klippel-Trenaunay-Weber syndrome is characterized by the triad of a port-wine stain, varicose veins, and bony and soft-tissue hypertrophy of an extremity. Recognition is usually possible during infancy or early childhood, and evaluation and treatment is important because morbidity may be minimized. We will review the clinical features, etiology, assessment, and treatment of patients with Klippel-Trenaunay-Weber syndrome.

[Klippel-Trenaunay syndrome]

The Klippel-Trenaunay syndrome is a rare congenital pathology which includes varices, hemangiomas and hypertrophy of limbs. The Authors report two cases and pay particular attention to the diagnostic and therapeutical protocols. Although these aspects are still open questions, the Authors conclude that conservative therapy is often sufficient while surgery is requested only in the severe forms.

Klippel-Trenaunay syndrome

The Klippel-Trenaunay syndrome, typically characterised by the triad of cutaneous haemangioma, venous varicosities, and limb hypertrophy, may also have a formes frustes presentation, with absence of the cutaneous naevus. A case is reported in a 75-year-old woman with a presumptive diagnosis of renovascular hypertension.

[Three-quadrant syndrome in Klippel-Trenaunay syndrome and primary lymphedema of both legs]

A 34-year-old woman with extensive Klippel-Trenaunay syndrome is presented. Clinical and radiological tests demonstrated that three quadrants are affected with haemangiomas, varicose veins and bone abnormalities. In addition, our patient suffers from congenital lymphoedema of both legs. Associated findings such as intestinal haemangiomata, vascular hamartomas, lipoma or arteriovenous abnormalities of the spinal cord were not apparent. The treatment is only symptomatic with compression bandages and an orthopaedic appliance for compensation of the different leg length.

Klippel-Trenaunay syndrome: clinical features, complications and management in children

Clinical features and management of 47 children with Klippel-Trenaunay syndrome treated since 1970 were reviewed. Haemangiomas and soft tissue and/or skeletal hypertrophy were present in all 47 patients; venous varicosities developed in 37 (79 per cent). There was no clinical evidence of macrofistulous arteriovenous communications in any patient. Thromboembolic episodes occurred in five children (11 per cent) and 25 (53 per cent) experienced thrombophlebitis. The Kasabach-Merritt syndrome was observed in 21 (45 per cent) and six (13 per cent) presented with high-output cardiac failure. Other manifestations included haematuria in five (11 per cent), rectal or colonic haemorrhage in six (13 per cent), and vaginal, vulval or penile bleeding in six (13 per cent) children with visceral and pelvic haemangiomas. In 26 patients (55 per cent) symptomatic treatment only was required. Surgery was undertaken in selected cases for complications of the haemangioma, for cosmetic reasons and for chronic venous insufficiency. Only one of four children who underwent resection of varicose veins improved. There was no death, but significant morbidity was associated with the treatment of Kasabach-Merritt syndrome and high-output cardiac failure.

Multiple spinal arteriovenous fistulas in Klippel-Trenaunay-Weber syndrome treated with platinum fibre coils

A 13-year-old girl with Klippel-Trenaunay-Weber syndrome and intradural extramedullary spinal arteriovenous fistulas is presented. Pre-embolization balloon test occlusions and embolization with platinum fibre coils were carried out in three sessions, after which the myelopathy and the intense back pain disappeared. Our conclusion is that spinal fistulas can be safely and effectively treated with fibre coils in combination with balloon testing.

[[Klippel-Trenaunay syndrome--an embryonic developmental disorder. A case report with reference to the orthodontic symptoms]

The Klippel-Trenaunay syndrome is a disturbance in the development of the mesodermal and ectodermal tissues occurring in utero. It is characterized by the clinical triad of unilateral soft tissue and bone hypertrophy, varicosities and hemangiomas. For dentists the orofacial manifestations of the syndrome are interesting: unilateral hypertrophy of the maxilla and mandible, mandibular joint and alveolar processes and tooth germs. In addition, the gingival margins are thickened, eruption is premature and there is marked facial asymmetry.