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Wang SK, Drucker NA, Gupta AK, Marshalleck FE, Dalsing MC. Diagnosis and management of the venous malformations of Klippel-Trénaunay syndrome. J Vasc Surg Venous Lymphat Disord 2018. [PMID: 28624001 DOI: 10.1016/j.jvsv.2016.10.084] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE A dearth of information exists in the literature regarding current practice in the management of Klippel-Trénaunay syndrome (KTS), a rare condition. We review and describe the etiology, diagnosis, and treatment of KTS. METHODS Relevant data were synthesized from a Medline review using a combination of the keyterms "Klippel" and "Trénaunay." The majority of hits described singular case reports and were subsequently excluded. The remaining papers were then reviewed and included on the basis of the quality of evidence and the authors' discretion. CONCLUSIONS KTS is characterized by a clinical triad of extremity varicosities, cutaneous vascular malformations, and hypertrophy of soft tissues and long bones. The diagnosis is clinically supplemented with magnetic resonance imaging and computed tomography. Although this syndrome is associated with significant comorbidities, such as pain, edema, ulcerations, and pruritus, it is rarely the cause of death. The backbone of treatment is nonoperative in nature but should be supplemented with minimally invasive, endovascular, and rarely open surgical procedures for refractory cases.
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Affiliation(s)
- S Keisin Wang
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind; Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Natalie A Drucker
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alok K Gupta
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind; Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | | | - Michael C Dalsing
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind; Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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Abstract
Klippel–Trenaunay syndrome (KTS) is a rare, sporadic, complex malformation characterized by the clinical triad of (1) capillary malformations (port wine stain); (2) soft tissue and bone hypertrophy or, occasionally, hypotrophy of usually one lower limb; and (3) atypical, mostly lateral varicosity. KTS is a mixed vascular malformation, with predominant capillary, venous and lymphatic components, without significant arteriovenous shunting. Management is largely conservative and the extent of diagnostic evaluation is determined by the planned treatment. Compression is the hallmark of conservative management; laser can be used to treat port wine stains. Imaging before vascular interventions must confirm venous anatomy and deep venous drainage. Techniques for ablation of superficial veins and malformations are individualized and may include sclerotherapy with alcohol or foam, endovenous thermal ablation or, as used most frequently in our practice, surgical stripping and phlebectomy. Intraoperative use of tourniquet will decrease bleeding, selective use of an inferior vena cava filter will prevent pulmonary embolism. A multidisciplinary approach to management of KTS is warranted.
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Affiliation(s)
- P Glovkzki
- Division of Vascular Surgery
- Gonda Vascular Center, Mayo Clinic
| | - D J Driscoll
- Department of Paediatrics
- Vascular Malformation Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
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Volz KR, Kanner CD, Evans J, Evans KD. Klippel-Trénaunay Syndrome: Need for Careful Clinical Classification. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2057-2065. [PMID: 27492391 DOI: 10.7863/ultra.15.08007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 11/20/2015] [Indexed: 06/06/2023]
Abstract
Klippel-Trénaunay syndrome (KTS) is a rare congenital malformation characterized by a triad of clinical presentations: (1) capillary malformations manifesting as a "port wine stain"; (2) limb hypertrophy; and (3) venous varicosities. It is distinguished from Parkes-Weber syndrome by the absence of substantial arteriovenous shunting. Due to the clinical implications of an arteriovenous fistula, differentiation between the two syndromes is important, as the prognosis and treatment greatly differ. We present a series of 5 cases of suspected KTS, while emphasizing the difficulties in distinguishing KTS from Parkes-Weber syndrome without diagnostic imaging and underscoring the importance of accurately classifying patients with the appropriate syndrome.
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Affiliation(s)
- Kevin R Volz
- School of Health and Rehabilitation Sciences, The Ohio State University, College of Medicine, Columbus, Ohio USA
| | - Christopher D Kanner
- School of Health and Rehabilitation Sciences, The Ohio State University, College of Medicine, Columbus, Ohio USA
| | - Julie Evans
- Division of Vascular Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio USA
| | - Kevin D Evans
- School of Health and Rehabilitation Sciences, The Ohio State University, College of Medicine, Columbus, Ohio USA
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Sermsathanasawadi N, Hongku K, Wongwanit C, Ruangsetakit C, Chinsakchai K, Mutirangura P. Endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy in treatment of klippel-trenaunay syndrome. Ann Vasc Dis 2014; 7:52-5. [PMID: 24719663 DOI: 10.3400/avd.oa.13-00111] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 01/26/2014] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Klippel-Trenaunay syndrome is composed of port-wine stain, limb hypertrophy and varicose veins. METHODS The two patients with Klippel-Trenaunay syndrome treated by endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy of the abnormal veins was conducted. RESULTS Radiofrequency thermal ablation resulted in successful occlusion of the incompetent anterior accessory great saphenous vein. Moreover, ultrasound-guided foam sclerotherapy showed complete occlusion of the residual veins. At 6 month follow-up, both patients markedly decreased leg symptoms including pain, cramping, limb swelling, and bulging of veins. CONCLUSION Radiofrequency thermal ablation combined with foam sclerotherapy is a minimally invasive procedure alternative to the standard invasive surgery and can be the option for saphenous ablation in Klippel-Trenaunay syndrome patients.
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Affiliation(s)
- Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kiattisak Hongku
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chumpol Wongwanit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanean Ruangsetakit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pramook Mutirangura
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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5
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Vascular anomalies of the extremities. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e3182961675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Dispenza K. Severe Pain Related to Klippel-Trénaunay-Weber Syndrome: A Case Study. Pain Manag Nurs 2011; 12:112-4. [DOI: 10.1016/j.pmn.2010.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 03/18/2010] [Accepted: 03/24/2010] [Indexed: 11/27/2022]
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Frasier K, Giangola G, Rosen R, Ginat DT. Endovascular radiofrequency ablation: A novel treatment of venous insufficiency in Klippel-Trenaunay patients. J Vasc Surg 2008; 47:1339-45. [DOI: 10.1016/j.jvs.2008.01.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 12/04/2007] [Accepted: 01/17/2008] [Indexed: 01/19/2023]
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Mofidi R, Nagy J, Levison RA, Griffiths GD. Beware of varicose veins in a patient with sturge-weber syndrome. Ann Vasc Surg 2007; 21:640-4. [PMID: 17532602 DOI: 10.1016/j.avsg.2007.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2006] [Revised: 02/18/2007] [Accepted: 03/07/2007] [Indexed: 01/19/2023]
Abstract
This report describes the case of a 21-year-old man with a history of Sturge-Weber syndrome and varicose veins. Examination of the left lower limb revealed the presence of significant port-wine staining, and hypertrophy. Duplex examination revealed a severely hypoplastic deep venous system with a tortuous, dilated, long saphenous vein, which was competent and responsible for a significant proportion of venous return from the left lower limb, thus confirming the diagnosis of Klippel-Trenaunay syndrome. The patient was counseled regarding the implications of the diagnosis and was treated conservatively. The association between these two rare syndromes has been previously reported in the nonvascular literature. We believe that features of the Sturge-Weber syndrome or other forms of mesodermal phakomatosis should alert a clinician to the presence of lower limb venous malformations, which will need to be investigated prior to embarking on what could be potentially detrimental venous surgery.
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Affiliation(s)
- R Mofidi
- Department of Vascular Surgery, Ninewells Hospital, Dundee, United Kingdom.
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Kihiczak GG, Meine JG, Schwartz RA, Janniger CK. Klippel-Trenaunay syndrome: a multisystem disorder possibly resulting from a pathogenic gene for vascular and tissue overgrowth. Int J Dermatol 2007; 45:883-90. [PMID: 16911369 DOI: 10.1111/j.1365-4632.2006.02940.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- George G Kihiczak
- Dermatology and Pediatrics, New Jersey Medical School, Newark, NJ 07103-2714, USA
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Kim YW, Lee BB, Cho JH, Do YS, Kim DI, Kim ES. Haemodynamic and Clinical Assessment of Lateral Marginal Vein Excision in Patients with a Predominantly Venous Malformation of the Lower Extremity. Eur J Vasc Endovasc Surg 2007; 33:122-7. [PMID: 17030131 DOI: 10.1016/j.ejvs.2006.06.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 06/04/2006] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The purpose of the present study was to determine the effects of the surgical excision of lateral marginal veins (LMVs) in patients with a venous malformation (VM) affecting the lower extremity. METHODS Preoperative and postoperative air plethysmography (APG), CEAP classification C scores, and venous clinical severity scores (VCSS) of the 25 VM patients who underwent LMV excision were compared. RESULTS After LMV excision, venous haemodynamic parameters revealed significantly increased ejection fraction (EF, 33.2 S.D.18.5% vs. 39.7 S.D.21.2%, P=.020), and reduced venous volume (VV, 235.0 S.D.141.8 ml vs. 198.0 S.D.114.1 ml, P=.016) and residual venous fraction (RVF, 62.4 S.D. 26.6% vs. 56.9 S.D. 25.3%, P=.046). Clinical assessments of affected limbs revealed significantly improved mean CEAP C scores and VCSS (preoperative score, 4.4 S.D.1.7 vs. postoperative score 2.4 S.D.1.7, P=.026) after LMV excision versus preoperative data. CONCLUSION Haemodynamic and clinical improvements were observed in patients with lower extremity VM after LMV excision.
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Affiliation(s)
- Y-W Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Rajaonarivony T, Randriamananjara N, Rakotoarisoa AJC, Rantomalala HYH, Ranaivozanany A. [A case of Klippel-Trenaunay-Weber syndrome of the hand: description and review of the literature]. Ann Cardiol Angeiol (Paris) 2005; 54:289-91. [PMID: 16237920 DOI: 10.1016/j.ancard.2005.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report the first malagasy case of a 10 years-old child with a Klippel-Trenaunay-Weber syndrome. The patient presented with cutaneous hemangioma, varicosities and unilateral hypertrophy of soft tissues of the left hand. Arteriovenous fistula was findings by the echo-doppler. Ligature of the fistula was performed.
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Affiliation(s)
- T Rajaonarivony
- Service de chirurgie cardiovasculaire et thoracique, CHU HJRA-Ampefiloha, BP 4150, 101 Antananarivo, Madagascar.
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Yildiz F, Yilmaz M, Cengiz M, Gürkaynak M, Cila AN, Doğan AI, Atahan IL. Radiotherapy in the management of Klippel-Trénaunay-Weber syndrome: report of two cases. Ann Vasc Surg 2005; 19:566-71. [PMID: 15986088 DOI: 10.1007/s10016-005-5027-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Klippel-Trénaunay-Weber syndrome (KTWS) is characterized by combined vascular malformations of capillary, venous, and lymphatic types usually observed during infancy or childhood. In this report, we describe two KTWS patients treated with radiotherapy after long-term conservative treatment or multiple surgical interventions. The first patient, a 15-year-old female, presented with vascular masses located on the right upper extremity. She was treated conservatively for 14 years, and amputation was offered at the age of 14 due to cardiac failure. A course of radiotherapy to a total dose of 40 Gy with conventional daily fractionation was administered as an alternative to the mutilating surgery, and prominent improvement both subjectively and objectively was detected 1 year after radiotherapy. The second patient, a 40-year-old male, suffered from huge vascular masses of both the trunk and lower extremities. Despite multiple surgical interventions and conservative treatment, disease progressed and neurological symptoms occurred due to compression of vertebral structures. He was administered a course of 30 Gy radiotherapy with 1.5 Gy daily fractions to the lower thoracic region and whole abdominal cavity. Six months after radiotherapy, subjective relief described by the patient but without any objective response was detected. Though considered as a benign disease, KTWS can cause life-threatening complications. The response of one of our patients is a hopeful finding for considering radiotherapy as an alternative treatment modality for these patients.
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Affiliation(s)
- Ferah Yildiz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara, Turkey.
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Abstract
Growth of the limb in a child can be impaired, with the coexistence of a vascular malformation. In these vascular bone syndromes, altered growth is manifest as overgrowth or hypotrophy. The vascular malformation is usually complex and gets progressively worse with time. The two types of vascular anomalies in limbs, fast-flow and slow-flow, can be associated with limb length discrepancies. The fast-flow vascular malformations together with arteriovenous fistulae are part of Parkes Weber syndrome, characterized by congenital red cutaneous staining, hypertrophy in girth and increasing of limb length, lymphedema, increasing skin alterations due to a distal vascular steal, and pain, all of which develop during childhood. Treatment is generally conservative. An affected lower extremity can be complicated by pelvic tilting and scoliosis because leg length discrepancy may reach 10 cm. To avoid such a course, stapling epiphysiodesis of the knee cartilages is often performed, but this orthopedic procedure may augment the worsening of the arterial venous malformation in the limb. Therefore, less aggressive orthopedic management is preferable. Slow-flow vascular anomalies associated with limb growth alteration include (1) a diffuse capillary malformation (port-wine stain) with congenital hypertrophy of the involved extremity which is non-progressive; (2) purely venous malformations invading skin, muscles and joints, with pain, functional impairment, a chronic localized intravascular coagulopathy requiring distinctive management, and usually a slight undergrowth of the affected extremity and progressing amyotrophy; (3) the triad of a port-wine stain, anomalous veins and overgrowth of the limb, often known as Klippel-Trenaunay syndrome, which requires orthopedic management to decide the optimal timing for epiphysiodesis (i.e. when leg length discrepancy is >2.5 cm). Varicose veins are sometimes surgically removed after ultrasonographic and Doppler evaluation has confirmed a normal deep venous system. Capillary malformations can be effectively treated with pulsed dye laser, but results are usually poor in distal extremities.
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Maari C, Frieden IJ. Klippel-Trénaunay syndrome: The importance of “geographic stains” in identifying lymphatic disease and risk of complications. J Am Acad Dermatol 2004; 51:391-8. [PMID: 15337982 DOI: 10.1016/j.jaad.2003.12.017] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Klippel-Trénaunay syndrome (KTS) is a rare congenital anomaly classically defined as the triad of vascular stain, soft tissue and/or bony hypertrophy, and venous varicosities. OBJECTIVE To determine whether the morphologic characteristics of the associated vascular stains in KTS are predictive of the presence of lymphatic involvement and/or complications. SETTING Outpatient dermatology practice, tertiary care medical center. METHODS We retrospectively reviewed all cases of KTS identified between January 1989 and September 2001 at the University of California San Francisco (UCSF) Department of Dermatology. Forty patients were identified. We further classified them by type of cutaneous vascular stain, either "geographic" or "blotchy/segmental." Patients were further classified as having definite, probable, possible, or no evidence of lymphatic disease. We also reviewed the charts for other possibly associated manifestations and complications of KTS. RESULTS Of those with sharply demarcated geographic stains (n=22), 21 had definite or probable evidence of lymphatic disease. Of those with blotchy port-wine stains (n=17), 16 had possible or no evidence of lymphatic disease (P <.001). Determination of the type of stain had 95% sensitivity and 94% specificity in differentiating the definite or probable presence of definite or probable lymphatic disease from possible or no evidence of lymphatic disease. Complications occurred in 19 (86%) of 22 patients with a geographic stain vs 7 of 17 (41%) with a blotchy/segmental stain (P <.003). CONCLUSION This study demonstrates that the presence of a geographic vascular stain is a predictor of the risk of both associated lymphatic malformation and complications in patients with KTS. Since these stains are present at birth, this clinical observation can help in identifying individuals with KTS at greatest risk for complications and in need of closer observation.
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Affiliation(s)
- Catherine Maari
- Division of Dermatology, University of Montreal Hospital Centre
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Bastida Eizaguirre M, Iturbe Ortiz de Urbina R. Asimetría de extremidades inferiores con manchas “en vino de Oporto”. An Pediatr (Barc) 2004; 60:589-90. [PMID: 15207174 DOI: 10.1016/s1695-4033(04)78332-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- M Bastida Eizaguirre
- Servicio de Pediatría, Hospital Santiago Apóstol, Olaguibel 29, 01004 Vitoria, Spain.
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Oderich GS, Panneton JM, Noel AA, Hofer JM. Relief of Iliofemoral Vein Occlusion with the Palma Bypass in a Patient with Klippel Trenaunay Syndrome. Ann Vasc Surg 2003; 17:449-55. [PMID: 14670026 DOI: 10.1007/s10016-003-0011-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Klippel Trenaunay syndrome is usually managed conservatively with surgery reserved for patients with symptomatic but mild cosmetic deformity or persistent venous hypertension despite nonoperative measures. Deep venous reconstruction is necessary in a small group of patients who present with significant chronic venous insufficiency due to hypoplastic, absent, or occluded deep venous outflow. Most often, venous outflow occlusion results from inadequate or surgically removed superficial collateral veins or from complications of endovascular procedures. In this article, we review the English-language literature and the Mayo Clinic experience, and report on a patient with Klippel Trenaunay syndrome who developed symptomatic iliofemoral venous occlusion following iliac vein stenting, which was successfully treated with a crossover saphenofemoral vein (Palma) bypass.
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