Management of Venous Malformations

Paediatric sclerotherapy of vascular anomalies of the hand and digits

AIM

Vascular anomalies in the hands and digits can cause pain, swelling and restrict the range of motion. Additionally, the small compartments they reside within portend challenges and possible risks in treatment. This study aims to evaluate the safety and efficacy of percutaneous sclerotherapy to treat vascular malformations in the hand and digits in paediatric patients.

MATERIALS AND METHODS

Metrics including size and location characteristics of the anomaly, procedural specifics, technical success, clinical success, and adverse events were recorded and further analysed.

RESULTS

Eight paediatric patients (5 males, 3 females) aged 5-17 years (mean 12 years) with vascular anomalies of the hands and digits treated with sclerotherapy were included. Three patients had arteriovenous malformation (AVMs), two venous malformation (VMs), and three venolymphatic malformation (VLMs) based upon imaging. Presenting symptoms included localised pain (n=8), swelling (n=7), decreased range of motion and function (n=3) and distal upper extremity numbness (n=1). Technical success was achieved in all (100%) patients. Seven of the eight patients (87.5%) followed up at six weeks and all reported at least partial reduction of symptoms (100%). Follow-up imaging was available for three patients with all showing decrease in the size of the malformation. There were no intraoperative complications or major adverse events. Three patients (37.5%) reported Society of Interventional Radiology (SIR) grade A/B minor adverse events (swelling [n=3], transient pain [n=3], and poor capillary refill [n=1]). Two patients (25%) benefited with a steroid prescription that successfully abated their symptoms.

CONCLUSION

Sclerotherapy appears to be a safe and effective treatment for vascular malformations in the hand and digits in paediatric patients.

The use of Sirolimus for an unresectable and refractory venous malformation: A case series

Vascular malformations (VM) may become symptomatic and extensive, leading to deranged coagulation and bleeding. Sirolimus®, an antiangiogenic agent, has recently emerged as treatment for VM. We report its short-term outcomes for VMs of the extremities. Case 1: A 47-year-old female reported left forearm pain. MRI confirmed a VM. Lesion shrinkage and pain relief were not achieved despite sclerotherapy. After 5 months on Sirolimus®, improved pain, decreased forearm circumference and decreased lesion size on MRI were observed. Case 2: 62-year-old male reported left knee pain. MRI and biopsy confirmed a VM. After 3 months on Sirolimus®, improved pain, decreased leg circumference, and decreased lesion size on MRI were observed. Our series demonstrates that Sirolimus® is efficacious in downsizing VMs with resultant symptom relief in the short-term. Other series has likewise shown effectivity in extensive and refractory lesions, with benefits outweighing side effects.

Regimens and Response Assessment in Minimally Invasive Image-Guided Therapies for Vascular Malformations: Insights from a Large Cohort Study at a Tertiary-Care Hospital

This retrospective study was aimed at characterizing vascular malformations (VMFs) presenting for minimally invasive image-guided therapies (MIT) at a tertiary-care center and evaluating treatment regimens and image-based outcomes using MRI. We analyzed demographic, disease-related, and radiologic features of VMFs presenting to interventional radiology between May 2008 and August 2020 using compendium vascular anomaly (Compva) criteria. MIT and specific agents were evaluated, and treatment effects were assessed through volumetry and mean signal intensity (MSI) on multiparametric longitudinal MRI. The statistics included the paired t-test, ANOVA, and Fisher's exact test. The cohort included 217 patients (mean age 30 ± 18.4 years; 134 female). Venous malformations were most common (47%). VMFs were frequently located in the head-neck region (23.5%), legs (23.04%), and arms (13.8%). Among 112 treatments, sclerotherapy was performed most frequently (63.9%), followed by embolization (19.3%). MRI showed a significant reduction in T2 MSI for venous (1107.95 vs. 465.26; p = 0.028) and decreased contrast media uptake for lymphatic malformations (557.33 vs. 285.33; p = 0.029) after sclerotherapy, while the lesion volumes did not change significantly (p = 0.8). These findings propose MRI-derived MSI as a potential non-invasive biomarker for assessing the response of VMF to MIT. By leveraging MRI, this study addresses challenges in managing rare diseases like VMFs, while advocating for standardized approaches and prospective studies to better link imaging findings with clinical outcomes.

Ultrasound-Guided Nd:YAG Laser Intervention in the Orofacial Region: Report of a Case of Multi-Focal Venous Malformation

Venous malformation is acongenital vascular system structure malformation caused by abnormal vascular endothelial cell morphology, which can occur in any tissue or organ of the oral and maxillofacial region. Laser treatment is currently a commonly used minimally invasive treatment. In this case, the patient with congenital multiple venous malformation was treated with Nd:YAG laser for the visible submucosal part, and the subcutaneous part under the chin tip was treated with ultrasound. The chin tip was treated with ultrasound guided by the chair to achieve the purpose of minimally invasive laser treatment. In this case's diagnosis and treatment process, we hope to provide a new idea for laser treatment of oromaxillofacial vein malformations.

Venous Malformations: Diagnosis, Management, and Future Directions

Venous malformations (VMs) represent the most common type of congenital vascular anomalies, characterized by slow-flow lesions arising from disorganized angiogenesis. These malformations can vary widely in size, location, and clinical impact, presenting significant challenges in diagnosis and management. A multidisciplinary approach is essential for optimizing care, with goals centered on symptom relief and functional preservation. Diagnostic evaluation typically involves clinical examination, imaging, and, in complex cases, genetic testing. Interventional radiology, particularly sclerotherapy and endovascular embolization, has become the first-line treatment, complemented by surgical and emerging molecular therapies, particularly targeting the mTOR/PI3K/AKT pathway. This review provides a comprehensive examination of the genetics, clinical presentation, and key diagnostic imaging aspects of VMs, along with a detailed discussion of current treatment modalities, emerging therapeutic techniques, and future directions for improving patient care.

The Prospective Natural History Study of Patients with Intractable Venous Malformation and Klippel-Trenaunay Syndrome to Guide Designing a Proof-of-Concept Clinical Trial for Novel Therapeutic Intervention

Background: The natural history of venous malformation (VM) and Klippel-Trenaunay Syndrome (KTS) has not been quantitatively studied. To obtain benchmarks to guide designing clinical trials to assess safety and efficacy of novel drug candidates, the clinical course of the patients was followed for 6 months. Methods and Results: This is a multicenter prospective observational study evaluating the change rate in lesion volume from baseline with magnetic resonance images, as the primary endpoint. In addition, disease severities, performance status (PS), pain visual analog scale (VAS) score, quality of life (QoL), infections, and coagulation markers were also evaluated. Thirty-four patients (VM = 17, KTS = 17, 1-53 of age; median 15.9 years) with measurable lesion volume were analyzed. There was no statistically significant difference in the lesion volume between baseline and day 180, and the mean change rate (standard deviation) was 1.06 (0.28). There were no baseline characteristics that affected the change in lesion volume over 6 months. However, there were patients who showed more than 20% volume change and it was suggested that the lesion volume was largely impacted by local infection. There were no statistically significant changes in pain VAS score, severity, PS, QoL score, D-dimer, and platelet count over 6 months within all patients analyzed. Conclusion: The results showed the representative natural course of VM and KTS for a 6-month period with objective change of lesion volume and other factors, suggesting that it is scientifically reasonable to conduct a Phase 2 proof-of-concept study without a placebo arm, using the results of this study as the control. Clinical Trial Registration: NCT04285723, NCT04589650.

Dabigatran etexilate is efficacious in consumptive coagulopathy and pain associated with venous malformations

OBJECTIVE

Consumptive coagulopathy treatment and pain management are crucial for patients with venous malformations (VMs). Dabigatran etexilate, a non-vitamin K antagonist oral anticoagulant, has known advantages compared with low-molecular-weight heparin and vitamin K antagonists, including oral administration, a more consistent pharmacokinetics/pharmacodynamics profile, a better safety profile, and no need for coagulation surveillance. In the present study, we tested the efficacy and safety of dabigatran etexilate for consumptive coagulopathy treatment and pain management for patients with VMs.

METHODS

To investigate the efficacy and safety of dabigatran etexilate in treating localized intravascular coagulation (LIC) associated with VM, we retrospectively collected data for 19 outpatients with VM and LIC, who had been treated with dabigatran etexilate from September 2019 to June 2021. The patients provided oral informed consent and underwent biologic blood testing, routine examinations, and determination of coagulation function before and after treatment. The dosage of dabigatran etexilate was 110 mg twice daily for adults and 55 mg twice daily for children.

RESULTS

All 19 patients had benefited from dabigatran etexilate treatment with coagulation improvement and pain relief. Pain had improved in all 16 evaluable patients. The fibrinogen and D-dimer levels had improved in 18 of 19 patients. The fibrin degradation product level had improved in 10 of 14 patients. None of patients reported lesion regression, appearance changes, or improvement in mobility. No significant differences were found in the D-dimer, fibrinogen, and fibrin degradation product levels between the short-term (<10 days) and long-term (≥10 days) use of the medication. Dabigatran etexilate was well tolerated by all patients. No bleeding event had occurred during follow-up.

CONCLUSIONS

The results of our study have confirmed the efficacy and safety of dabigatran etexilate in treating pain and LIC in patients with VMs. Dabigatran etexilate is a suitable choice preoperatively to modify coagulation function and pain in patients with VMs.

Clinical results of polidocanol sclerotherapy in venous malformation treatment: Patient-perceived improvement and satisfaction

PURPOSE

This study evaluated the results of polidocanol sclerotherapy in the treatment of venous malformations (VM) including patient satisfaction, perceived improvement, and predictors of satisfaction.

MATERIAL AND METHOD

Patients with VM that underwent polidocanol foam sclerotherapy between June 2013 and July 2021 in a single center were retrospectively evaluated. Patient demographics, VM, and treatment characteristics were analyzed. Patient-reported outcomes and satisfaction were analyzed with a questionnaire.

RESULTS

This study included 232 (136, 58.6%, female) patients. The mean age was 24.49 ± 12.45 years (range 3-72). The clinical response rate was 82.3%. The rate of satisfaction was 82.3%, and 116 (50%) patients were significantly satisfied. There were no major complications. Clinical response and VM margin were related to satisfaction (p < 0.01, p = 0.012, respectively). Clinical response to pretreatment swelling was related to significant satisfaction (p = 0.02).

CONCLUSION

Polidocanol sclerotherapy was safe and effective in VM treatment with high satisfaction and low complication rates.