Clinicoradiologic predictors of sclerotherapy response in low-flow vascular malformations

Percutaneous image-guided cryoablation of venous malformation and fibro-adipose vascular anomaly: prognostic factors of clinical efficacy

OBJECTIVE

To assess the prognostic factors for clinical and radiological responses to percutaneous image-guided cryoablation (CA) in treating venous malformation (VM) and fibro-adipose vascular anomaly (FAVA).

MATERIALS AND METHODS

Fifty-five patients (12 males, 43 females; median age: 30 years) with symptomatic lesions (median VAS pain score: 70; median initial volume: 12.2 mm³) underwent CA between 2012 and 2023. CA was a first-line treatment in 23 patients (42%) and second-line in 32 (58%). Lesions were Goyal grade 1 in 24 cases (43%) and located on extremities in 44 (80%). Technical efficacy was assessed using MRI and applying RECIST criteria, while clinical efficacy was based on changes in VAS pain scores. Prognostic factors for residual pain were analyzed using univariable and multivariable analyses.

RESULTS

With a median follow-up of 13 months, technical success was achieved in all cases, and 20% of patients underwent multiple sessions. Technical efficacy was observed in 69% of cases, with 33% achieving complete response and 36% partial response (mean volume reduction: 47%). Clinical efficacy was reached in 72% of cases. Univariable analysis linked residual pain to sex (female, p = 0.013), initial pain level (p = 0.014), Goyal grade (p = 0.029), and residual volume (p = 0.012). Multivariable analysis revealed that grade (p = 0.035), post-therapeutic volume (p = 0.048), and completeness of treatment (p = 0.029) were statistically significant predictors.

CONCLUSION

Cryoablation is an effective management strategy for venous malformation and FAVA, with residual volume emerging as a significant indicator of clinical success.

KEY POINTS

Question Venous malformations (VA) and fibro-adipose vascular anomalies (FAVA) often cause chronic pain, with limited effective treatment options. Identifying predictors of pain relief following cryoablation could optimize patient outcomes. Findings Cryoablation achieved 72% pain relief for VA and FAVA. High lesion grade, treatment completeness, and residual volume were significantly associated with residual pain. Clinical relevance Cryoablation provides an effective, minimally invasive treatment for VA and FAVA, achieving significant pain relief while identifying predictors to optimize patient selection and outcomes.

Effect and safety of ethanolamine oleate in sclerotherapy in patients with difficult-to-resect venous malformations: A multicenter, single-arm study

OBJECTIVE

To evaluate the effect and safety of sclerotherapy in patients with difficult-to-resect venous malformations treated with ethanolamine oleate.

DESIGN AND SETTING

This investigator-initiated clinical trial employed a multicenter, single-arm design and was conducted in Japan.

PATIENTS

Overall, 44 patients with difficult-to-resect venous malformations were categorized into two cohorts: 22 patients with cystic-type malformations and 22 patients with diffuse-type malformations, including children (<15 years old).

INTERVENTIONS

Adult patients received injections of 5% ethanolamine oleate solution, double diluted with contrast or normal saline, with a maximum dose of 0.4 mL/kg. The same method of administration was used for children (<15 years old). The maximum volume of the prepared solution in one treatment was 30 mL.

EVALUATION METHODS

Treatment effect was assessed by evaluating the difference in lesion volume using magnetic resonance imaging as a primary endpoint and differences in pain using a visual analog scale as a key secondary endpoint.

RESULTS

Among the 45 patients who consented, one was excluded owing to potential intracranial involvement of venous malformations during screening. Regarding the primary outcome, 26 of 44 patients (59.1%, 95% confidence interval: 44.41-72.31%) achieved ≥ 20% reduction in malformation volume, with 16 patients having cystic lesions (72.7%, 51.85-86.85%) and 10 patients having diffuse lesions (45.5%, 26.92-65.34%). Both cohorts showed significant improvement in self-reported pain scores associated with lesions 3 months post-sclerotherapy. No death or serious adverse events occurred. Hemoglobinuria was observed in 23 patients (52%), a known drug-related adverse event. Prompt initiation of haptoglobin therapy led to full recovery within a month for these patients.

CONCLUSIONS

Ethanolamine oleate shows potential as a therapeutic sclerosing agent for patients with difficult-to-resect venous malformations.

Case report: A rare case of multifocal, combined lymphatic-venous malformation

Vascular malformations, including lymphatic-venous malformations (LVMs), are complex and can lead to significant morbidity. This case report details the management of a rare multifocal, combined LVM in a 3-month-old male, misdiagnosed as a right inguinal hernia prenatally. Postnatal imaging revealed multiloculated cystic masses extending from the mons pubis to the right groin, scrotum, and thigh. Doppler ultrasound and MRI demonstrated the extent of the masses, with the largest cyst measuring 4 × 4 × 2 cm. Initial surgical excision and debulking were performed; however, the lesion recurred 6 months later. Given the complexity and involvement of truncal vessels, complete excision was not feasible, and sclerotherapy with intralesional Bleomycin injections was initiated. After the first Bleomycin injection, a significant reduction in lesion size was observed. However, 6 months later, the lesion recurred and enlarged, necessitating a second Bleomycin injection. Subsequent follow-ups showed further reduction in lesion size. Unfortunately, 2 years later, the patient experienced diffuse cystic infiltration of the pelvis and right lower extremity due to treatment delays caused by the COVID-19 pandemic. Imaging at this stage revealed a cystic mass in the right pelvic cavity measuring 10 × 6 × 5 cm. Two additional sessions of Bleomycin injections were performed, resulting in a successful resolution of the cystic masses. Regular follow-ups have shown that the LVMs remain under control, with no symptoms and no concerns from the family. This case underscores the complexities involved in diagnosing and managing multifocal, combined LVMs. It suggests that Bleomycin sclerotherapy can be a valuable, minimally invasive alternative to more extensive surgical procedures, particularly when critical structures are involved. The patient's condition has been successfully managed with a combination of surgical and sclerotherapy interventions, ultimately resulting in symptomatic relief and cosmetic improvement.

Intralesional injection of bleomycin in the management of low flow vascular malformations: Results and factors affecting the outcome

OBJECTIVE

Ethanol has been a commonly used sclerosant for low-flow vascular malformations, but it carries a high risk of complications. Bleomycin has been recently introduced as a potentially effective treatment. The aim of this study was to evaluate the safety and efficacy of bleomycin intralesional injection for the treatment of low-flow vascular malformations and determine the different factors affecting the outcome.

PATIENTS AND METHODS

A total of fifty patients with low-flow vascular malformations were enrolled in the study between April 2020 and March 2022. All patients underwent preoperative duplex ultrasound and magnetic resonance angiography. The procedure was performed under ultrasound and fluoroscopic guidance. All patients were assessed for the objective improvement, ultrasound assessment, and patient-reported outcome.

RESULTS

The overall rate of objective improvement was 79.53% (78.05% in venous and 87.5% in lymphatic malformations), whereas 81.25% of the patients showed a degree of size reduction or complete obliteration on postoperative ultrasound. The patient-reported outcome analysis showed a statistically significant improvement in the mean score for the pain, overall symptoms, and self-confidence. On regression analysis, the only factor associated with poor objective outcome was diffuse lesions (ill-defined or extending in more than one body region or one compartment). No major complications were recorded.

CONCLUSIONS

Bleomycin intralesional injection is a safe and effective treatment for low-flow vascular malformations.

A Clinical Study of Histopathological and Clinical Image Changes After Sclerotherapy of Lip Venous Malformations

Venous malformations (VMs) are histopathologically benign but can greatly impair patients' quality of life. Screlothprapy is known to be effective in improving symptoms without a scar, but surgical resection of residual lesions is sometimes necessary due to inadequate reduction. However, there is no consensus on what criteria should be used to consider switching to surgical treatment, and individualized decisions must be made for each case. To investigate the factors that contribute to the lack of efficacy of sclerotherapy in reducing lesions and how to predict this, the authors performed a retrospective clinical imaging and histopathological study of 6 cases of labial vein malformations treated with sclerotherapy and 3 cases without sclerotherapy. Clinical image investigations are based on magnetic resonance imaging before and after sclerotherapy. The authors found a significant decrease in the percentage of cystic components in the total lesion of VMs after sclerotherapy. Histopathological investigations are based on resected VMs with or without sclerotherapy. Elastica van Gieson stains suggested a significant increase in fibrotic tissue inside VMs treated with sclerotherapy compared with those without. In conclusion, magnetic resonance imaging signal changes inside the VMs after sclerotherapy was observed, and it may reflect fibrosis of the tissue. These changes in the VMs after sclerotherapy may reduce the effect of sclerotherapy on tissue reduction should be considered.

Vascular anomalies: nomenclature, classification, and imaging algorithms

There is a lot of ambiguity in the usage of correct terminology in the description of vascular malformations and tumors. Hemangioma and arteriovenous malformation (AVM) are the most commonly used terms and are the mostly incorrectly used as well! The aim of this review article was to lay out the correct nomenclature and describe the correct usage for the physicians and radiologists involved in diagnosing and managing these lesions. We describe the various classification systems which have been devised to define the multiple entities included under vascular anomalies. The latest classification system that should be adhered to is per the International Society for the Study of Vascular Anomalies, approved at the 20th ISSVA Workshop held in Melbourne in April 2014, last revised in May 2018. The main features of the latest revision have been highlighted. This classification, however, does not list the diagnostic clinico-radiological features for each entity. In addition, guidelines regarding the appropriate use of available imaging modalities are lacking in the literature. We, hereby, aim to address these pertinent issues in this review article.

A nomogram for predicting sclerotherapy response for treatment of lymphatic malformations in children

Purpose

In this manuscript, we purposed to identify the prognostic factors for treatment of lymphatic malformations in children using polidocanol foam combined with pingyangmycin and to construct nomogram for predicting sclerotherapy response.

Methods

A retrospective analysis of 77 children having LMs who underwent sclerotherapy using polidocanol foam combined with pingyangmycin under ultrasound display from January 2017 to April 2020 was done. The clinical response was graded as excellent (≥ 90%), good (≥ 50%, < 90%), and poor (< 50%). More than 50% was considered as acceptable response. Prognostic factors were identified by Pearson’s Chi-square or Fisher’s exact test and multivariable logistic regression model was used to construct a nomogram to predict sclerotherapy response. The discrimination and calibration of nomogram were verified through the receiver operating characteristic cure and calibration plots.

Results

The mean number of treatment sessions was 3.1 (range, 1–6). Among 77 patients, 58 patients (75.3%) had excellent response to treatment (≥ 90%) and 68 patients (88.3%) had an acceptable response (≥ 50%, < 90%). Clinical disfigurement (P = 0.014), skin discoloration (P = 0.040), morphological subtype (P < 0.001) and extent of the lesion (P < 0.001) correlated with clinical response to sclerotherapy in LMs. Sclerotherapy response was predicted through nomogram constructed in this study, which shows good calibration and discrimination. Also, focal lesion and macrocystic or mixed morphological subtype lesion were seen more often in lower number of treatment sessions among the patients with excellent response.

Conclusions

An acceptable response to sclerotherapy using polidocanol foam combined with pingyangmycin was achieved in majority of LMs in children with extremely low complication rates. Nomogram based on the prognostic factors of sclerotherapy response for LMs in children was shown to possess an excellent performance to predict the probability of LMs sclerotherapy response.

Successful Sclerotherapy for Cervicofacial Macrocystic Lymphatic Malformations Using Polidocanol and Pingyangmycin Combined Foam Sclerosants

Background: Sclerotherapy is the first-line therapeutic method for lymphatic malformations (LMs). This retrospective cohort study evaluated the effectiveness and safety of a novel combined foam sclerosant: polidocanol and pingyangmycin foam (PPF), for treating cervicofacial macrocystic LMs. Methods and Results: From July 2018 to October 2020, 51 patients with cervicofacial macrocystic LMs were enrolled in this study. All patients received intralesional 3% polidocanol or PPF injections. The outcome was evaluated regarding demographic and clinical characteristics, degree of treatment response, and post-treatment complications. Overall, 16 patients (31.4%) underwent PPF sclerotherapy. All these patients (100%) showed remarkable reduction in lesion size within three sessions. Excellent responses were shown in 88.5% of these patients within three sessions, which is higher than single polidocanol sclerotherapy (80%). The average sessions (duration) of PPF sclerotherapy were 2.5, which was significantly shorter than the single foam sclerotherapy (p < 0.05). Treatment duration was significantly associated with age, lesion location, lesion size, and number of cysts (p < 0.05). No severe complications were noted in this study. Local or systemic complications, such as swelling and mild fever occurred but subsided without any specific treatment. Conclusions: PPF is a safe, and effective combined foam sclerosant for the treatment of cervicofacial macrocystic LMs. This combined foam can improve treatment response and reduce treatment duration compared with a single sclerosant. It can be broadly used if further large-scale clinical trials verify its efficacy and safety.

Clinical Uses and Short-Term Safety Profile of Ethiodized Poppy Seed Oil Contrast Agent in the Diagnosis and Treatment of Vascular Anomalies and Tumors

Background: There is a sparsity of data on the use of ethiodized poppy seed oil (EPO) contrast agent (Lipiodol) in patients. We investigated the safety of EPO in children, adolescents, and some adults for diagnostic and therapeutic interventions. Methods: All patients who underwent procedures with EPO between 1995 and 2014 were retrospectively included. Demographic characteristics, diagnosis, dose, route of administration, preparation of EPO in combination with other agents, and complications were recorded. Results: In 1422 procedures, EPO was used for diagnostic or treatment purposes performed in 683 patients. The mean patient age was 13.4 years (range: 2 months–50 years); 58% of patients were female. Venous malformations (n = 402, 58.9%) and arteriovenous malformations (n = 60, 8.8%) were the most common diagnosis. Combined vascular anomalies included capillary–lymphatic–venous malformations, fibroadipose vascular anomalies (n = 54, 7.9%), central conducting lymphatic anomalies (n = 31, 4.5%), lymphatic malformations (n = 24, 3.5%), aneurysmal bone cysts (n = 22, 3.2%), and vascularized tumors (n = 11, 1.6%). In 1384 procedures (96%), EPO was used in various combinations with sclerosing and embolization agents, including sodium tetradecyl sulfate, ethanol, and glue. The mean volume of EPO used in interventions was 3.85 mL (range: 0.1–25 mL) per procedure with a mean patient weight of 45.9 kg (range: 3.7–122.6 kg) and a weight-adjusted dose of 0.12 mL/kg (range: 0.001–1.73 mL/kg). In 56 procedures (4%), EPO was used as a single agent for diagnostic lymphangiography. The mean volume was 4.8 mL (range: 0.3–13 mL) per procedure with a mean patient weight of 27.4 kg (range: 2.4–79.3 kg) and a weight-adjusted dose of 0.2 mL/kg (range: 0.04–0.54 mL/kg). Procedural-related complications occurred in 25 (1.8%) procedures. The 20 minor and 5 major complications were related to the primary treatment agents. None of them were directly related to EPO. No allergic reactions were noted. Conclusion: The use of an ethiodized poppy seed oil contrast agent in children, adolescents, and adults for diagnostic or therapeutic purposes is safe.