Endovascular Treatment of Slow-Flow Vascular Malformations

https://doi.org/10.1053/j.tvir.2013.01.003Get rights and content

Symptomatic slow-flow vascular malformations include venous malformations and lymphatic malformations, as well as combined anomalies. Endovascular therapy, consisting mainly of intralesional sclerosant injection, is now accepted as the primary treatment for most of these lesions. Magnetic resonance imaging and ultrasonography supplement physical examination for diagnosis and assessment of the extent of malformation. Endovascular treatment is usually carried out under general anesthesia. Sclerosants for venous malformations include ethanol, 3% sodium tetradecyl sulfate, and bleomycin. Lymphatic malformations can be injected with doxycycline, bleomycin, OK-432, or other sclerosants. Complications of sclerotherapy include tissue necrosis, peripheral nerve injury, hemoglobinuria, deep vein thrombosis, and pulmonary embolism. Although most vascular malformations are not cured, the majority of patients benefit from endovascular treatment.

Section snippets

Clinical Evaluation of the Patient

Slow-flow vascular malformations include venous malformations (VMs) and lymphatic malformations (LMs), as well as cutaneous capillary malformation (CM) and combined lesions. The clinical evaluation involves a focused medical history and physical examination and a review of imaging studies and basic laboratory values.1, 2, 3, 4 Malformations can be focal, multifocal, or diffuse, involving an entire limb or muscle group. They can involve any tissue layer. Physical features to look for include

Indications for Endovascular Treatment

VMs and LMs do not regress spontaneously and tend to enlarge and become more symptomatic over time. Indications for treatment include recurrent swelling, pain, deformity, thromboembolic complications, and sepsis. Interference with physical activity and abnormal gait because of pain are strong indications for treatment. Bulky vascular malformations negatively affect the growth of the developing skeleton. Treatment of these is best started before permanent deformity has occurred.

Relative

Procedural Steps for VM of the Lower Extremity

Due to the requirement for patient immobility during the procedure and patient comfort, the use of general anesthesia is highly recommended. Patients should have adequate hydration prior to the procedure. Some practitioners use steroids (eg, dexamethasone, 0.1 mg/kg intravenous [IV]) prior to sclerosis.

When treating an extensive VM of the lower extremity, I like to prepare the entire limb and place a peripheral IV in a pedal vein to be able to perform an ascending venography if needed and to

Choice of Sclerosant for Treating VMs

It has been widely stated that absolute ethanol is the most effective sclerosant with the lowest rate of recanalization. This may be true, but extensive VMs recanalize regardless of the sclerosant used. Disadvantages of ethanol include potential severe systemic effects (intoxication, hypoglycemia, cardiac arrhythmias, and cardiovascular collapse) and an increased rate of severe local complications, including skin necrosis and neuropathy, compared with detergent sclerosants. Sensory neuropathy

Procedural Steps for Macrocystic LM

After preparation and draping of the skin overlying the macrocytic LM, the largest cyst is cannulated with ultrasound guidance and fluid is aspirated. The remaining cysts are then cannulated and aspirated in a similar fashion. Doxycycline can be mixed with iodinated contrast to a final concentration of 10 mg/mL of doxycycline and injected into the drained cysts under fluoroscopic or ultrasound guidance (Fig. 3). The cystic spaces are filled with the sclerosant but care should be taken not to

Overcoming Technical Challenges

Below is a list of potential technical challenges that may be encountered and suggestions as to how to deal with them.

  • (1)

    It is easy to misdiagnose contrast extravasation as a VM. Findings that suggest contrast extravasation include linear margins, lack of visualization of any draining veins, and failure of contrast medium to clear after a few seconds. When in doubt, do not inject sclerosant as it may cause significant tissue necrosis and neuropathy if it is not intravascular.

  • (2)

    When a large VM

Postprocedure Care After Sclerotherapy

VMs: The type of care necessary depends on the size and location of the lesion. Patients with small lesions and a low risk of complications are recovered until they are alert and drinking well and are then discharged home. Patients are instructed to elevate the treated area as much as possible in the first 24 hours. Patients with more extensive lesions are observed in the hospital for 23 hours, during which time they receive IV fluids, antiinflammatory medication, and analgesics (usually

Skin Necrosis

This is the most common complication of sclerotherapy of VMs. Usually, it can be predicted by the appearance of skin at the end of the procedure. Areas of blanching or discoloration with a clearly defined margin usually herald skin necrosis. Warn the patient or parent, and advise them to keep the area clean and apply antibiotic ointment and a dressing. See the patient frequently in the clinic. In the presence of full-thickness skin necrosis, polymer dressings are useful to keep the lesion clean

Clinical Follow-up

Timing and frequency of clinical follow-up depends upon the treatment plan and the presence or absence of complications. All patients should receive a postprocedure follow-up call a few days after returning home to make sure they are not experiencing any adverse effects. Those who are doing well can be reassessed in a clinic about 6 weeks after the procedure. Ultrasonography is useful in showing whether there are any residual lesions requiring repeat treatment. Alternatively, if staged

Expected Outcomes

Patients with VM should be counseled, prior to the onset of treatment, that they have a genetic condition that usually is not curable. The goal of sclerotherapy is to shrink the malformed channels, reduce venous insufficiency and decrease swelling and pain. The majority of patients undergoing sclerotherapy for pain show an improvement in their symptoms after sclerotherapy, even if imaging shows residual VM. Some of the treated channels would recanalize. Recurrence of symptoms can be minimized

References (14)

There are more references available in the full text version of this article.

Cited by (0)

View full text
Copyright © 2013 Elsevier Inc. All rights reserved.