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Shum A, Beydoun AS, Khalifee E, Carlberg V, Plunk M, Chun R. Preoperative n-BCA embolization in the resection of submandibular lymphatic malformations refractory to sclerotherapy treatment: A pilot case series. Int J Pediatr Otorhinolaryngol 2023; 168:111510. [PMID: 37003014 DOI: 10.1016/j.ijporl.2023.111510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 03/06/2023] [Accepted: 03/11/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Lymphatic malformations in the submandibular neck pose unique challenges to treatment that elevate their risk of recurrence. This case series provides a review of five patients, previously treated with sclerotherapy or with a history of multiple infections, who were treated in a novel fashion: single-stage resection using preoperative n-butyl cyanoacrylate (n-BCA) glue embolization. METHODS We performed a retrospective medical record review of five patients who underwent single-stage n-BCA embolization by Interventional Radiology followed by surgical resection by Otolaryngology, including a review of their symptoms, previous treatments, and post-treatment surveillance, with follow-up ranging from 4 to 24 months after the treatment of interest. RESULTS All study subjects had unremarkable perioperative courses, and four patients did not demonstrate any evidence of disease recurrence or persistence during the follow-up period. One patient was found to have a small area of persistent disease on post-treatment imaging, but has remained symptom free. CONCLUSIONS Treatment of submandibular lymphatic malformations with n-BCA embolization followed by surgical resection can be performed in a single stage. This case series demonstrates that this approach can yield durable relief of symptoms, even in patients whose lesions were refractory to previous treatments.
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Affiliation(s)
- Axel Shum
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA.
| | - Ahmed Sam Beydoun
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA.
| | - Elie Khalifee
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Valerie Carlberg
- Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA; Medical College of Wisconsin, Department of Dermatology, Milwaukee, WI, USA.
| | - Matthew Plunk
- Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA; Medical College of Wisconsin, Department of Radiology, Milwaukee, WI, USA.
| | - Robert Chun
- Medical College of Wisconsin, Department of Otolaryngology, Milwaukee, WI, USA; Children's Wisconsin, Department of Otolaryngology/Medical College of Wisconsin, Milwaukee, WI, USA.
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2
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Giese RA, Valero C, Shah JP. Surgical management of vascular tumors and malformations of the head and neck in adults. J Oral Pathol Med 2022; 51:854-859. [PMID: 35467767 DOI: 10.1111/jop.13302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/12/2022] [Indexed: 11/28/2022]
Abstract
Vascular tumors and malformations present a diagnostic and therapeutic challenge to many physicians. Because these lesions are rare, few surgeons have enough experience with them other than those practicing in tertiary vascular anomaly treatment centers. Some patients may have been misdiagnosed or mistreated during childhood and present in adult age with either recurrence or with an untreated lesion. Ideally, a multidisciplinary treatment team should be involved to discuss management with the patient including specialists in surgery, interventional radiology, pathology, hematology, genetics, and dermatology. As our understanding of the pathogenesis of these lesions grows, novel therapies are being employed which may decrease the need for surgery. Nevertheless, some lesions need definitive treatment with surgery. Improving understanding of the surgical management of vascular anomalies will improve cosmetic and functional outcomes for patients.
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Affiliation(s)
- Rachel A Giese
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Cristina Valero
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jatin P Shah
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Oncology, Radiotherapy and Plastic Surgery, Sechenov University, Moscow, Russia
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3
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Clemens RK, Sebastian T, Kerr C, Alomari AI. Clinical Uses and Short-Term Safety Profile of Ethiodized Poppy Seed Oil Contrast Agent in the Diagnosis and Treatment of Vascular Anomalies and Tumors. Diagnostics (Basel) 2021; 11:diagnostics11101776. [PMID: 34679474 PMCID: PMC8534402 DOI: 10.3390/diagnostics11101776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Robert K. Clemens
- Vascular Center, Cantonal Hospital Baden, CH-5404 Baden, Switzerland
- Department of Radiology and Vascular Anomalies Center, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (C.K.); (A.I.A.)
- Correspondence: ; Tel.: +41-44-922-23-08
| | - Tim Sebastian
- Clinic for Angiology, University Hospital Zurich and University Zurich, CH-8091 Zurich, Switzerland;
| | - Cindy Kerr
- Department of Radiology and Vascular Anomalies Center, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (C.K.); (A.I.A.)
| | - Ahmad I. Alomari
- Department of Radiology and Vascular Anomalies Center, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (C.K.); (A.I.A.)
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4
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Ouchi K, Tsuchiya K, Iehara T, Nishimura A, Konishi E, Hosoi H. Lethal prognosis of an infant with intraperitoneal large venous malformation. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:512-515. [PMID: 34401614 PMCID: PMC8358283 DOI: 10.1016/j.jvscit.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/22/2021] [Indexed: 12/02/2022]
Abstract
Intraperitoneal venous malformations are uncommon. Therefore, the prognosis of patients has not been determined, and appropriate treatments have not been established. We have reported the case of a neonate with an extensive intraperitoneal venous malformation. She did not have a developmental disorder nor a functional disability; thus, she was observed without treatment. However, the patient died suddenly of obstructive venous return disorder due to thrombosis in a vein draining from the venous malformation, followed by blood pooling in the expanding venous malformation. Extensive intraperitoneal venous malformations can be associated with a lethal prognosis owing to thrombosis. Anticoagulation therapy should be considered proactively for prophylaxis of thrombotic dysfunction.
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Affiliation(s)
- Kazutaka Ouchi
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kunihiko Tsuchiya
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoko Iehara
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ayako Nishimura
- Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Eiichi Konishi
- Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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5
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El Naamani K, Carrasco J, Ramesh S, Milman T, Abbas R, Sweid A, Zhou S, El Hajjar R, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Preoperative Ultrasound-Guided Percutaneous Embolization of Orbital Lymphaticovenous Malformations Using Onyx. World Neurosurg 2021; 154:13-20. [PMID: 34245882 DOI: 10.1016/j.wneu.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
The treatment of orbital lymphaticovenous malformations (OLVMs) has evolved from simple surgical resection to a multimodal approach consisting of sclerosing agents, embolization, and resection depending on the specific components that compose the lesion. Here we present a representative case series of 5 nonconsecutive patients who underwent percutaneous embolization of OLVMs with the Onyx Liquid Embolic System (Medtronic, Dublin, Ireland) before surgical resection between 2019 and 2021. OLVMs are rare, benign, congenital lesions that grow with age and can become symptomatic and disabling. Treatment can be conservative or invasive; depending on the clinical presentation and characteristics of the lesions, treatment modalities can vary. Preoperative percutaneous embolization of OLVMs with the Onyx system is a promising technique, as demonstrated in this case series.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Jacqueline Carrasco
- Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | | | - Tatyana Milman
- Occular Pathology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Siwei Zhou
- Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Rayan El Hajjar
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
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6
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Newly Developed N-butyl Cyanoacrylate (EG glue) for Arterial Embolization: A Preclinical Study in Rabbit Renal Artery. Macromol Res 2021. [DOI: 10.1007/s13233-021-9022-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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7
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Gallant SC, Chewning RH, Orbach DB, Trenor CC, Cunningham MJ. Contemporary Management of Vascular Anomalies of the Head and Neck-Part 1: Vascular Malformations: A Review. JAMA Otolaryngol Head Neck Surg 2021; 147:197-206. [PMID: 33237296 DOI: 10.1001/jamaoto.2020.4353] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Vascular anomalies of the head and neck are relatively rare lesions. Management is challenging because of the high likelihood of involvement of functionally critical structures. Multiple modalities of treatment exist for vascular anomalies of the head and neck, including medical therapies, sclerotherapy and embolization procedures, and surgery. This review focuses on the accurate diagnosis and the relative roles of the various therapeutic options. Observations Vascular anomalies are classified by the International Society for the Study of Vascular Anomalies into 2 major groups: vascular tumors and vascular malformations. Vascular tumors encompass proliferative lesions ranging from infantile and congenital hemangiomas to kaposiform hemangioendothelioma. Alternatively, vascular malformations are embryologic errors in vasculogenesis. This article focuses on the management of vascular malformations. The 3 primary vascular malformation subclassifications are lymphatic, venous, and arteriovenous. The burden of disease, diagnosis, and current management options are discussed in detail for each subtype. Conclusions and Relevance Most vascular malformations of the head and neck require a multidisciplinary approach. Available medical, interventional radiologic, and surgical interventions are constantly evolving. Optimization of function and cosmesis must be balanced with minimization of treatment-associated morbidity. Otolaryngologists-head and neck surgeons must remain up to date regarding options for diagnosis and management of these lesions.
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Affiliation(s)
- Sara C Gallant
- Department of Otolaryngology and Communication Sciences, Boston Children's Hospital, Boston, Massachusetts.,Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts
| | - Rush H Chewning
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Vascular and Interventional Radiology, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Darren B Orbach
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Vascular and Interventional Radiology, Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Cameron C Trenor
- Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Michael J Cunningham
- Department of Otolaryngology and Communication Sciences, Boston Children's Hospital, Boston, Massachusetts.,Vascular Anomalies Center, Boston Children's Hospital, Boston, Massachusetts
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8
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Puccia R, Staricha K, Carlberg VM, Moe D, Chun R. Utilizing immediate preoperative n-BCA in the resection of head and neck venous and lymphatic malformations. Int J Pediatr Otorhinolaryngol 2020; 138:110388. [PMID: 33152979 DOI: 10.1016/j.ijporl.2020.110388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/13/2020] [Accepted: 09/13/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE/OBJECTIVE To add to the current literature on single stage excision of head and neck vascular malformations with preoperative n-butyl cyanoacrylate (n-BCA) glue. Unlike previous studies, this series includes pediatric and adult patients, highlights a single stage partial excision of a complex venous malformation, and describes the first description of using glue prior to resection of a macrocystic lymphatic malformation. STUDY DESIGN Case series with chart review. SETTING Tertiary-care adult and pediatric hospital. SUBJECTS AND RESULTS Four patients (3 males - 9, 13, 25 years, 1 female - 61 years) underwent same day excision of head and neck vascular malformations utilizing immediate preoperative n-BCA glue embolization performed by interventional radiology and otolaryngology, as described by Tieu et al. The indications for resection included bleeding (1/4), pain (3/4), cosmetic deformity (3/4), and discomfort with denture wear (1/4). Prior interventions included none (1/4), cautery and primary closure to control acute hemorrhage (1/4), and sclerotherapy (2/4). Treatments included complete embolization and resection of simple venous malformation (VM)s of the oral cavity/lip (2/4), partial embolization and resection of a complex hemifacial venous malformation (VM) (1/4), and complete embolization and resection of a lymphatic malformation (LM) (1/4). On average, 97 min of anesthesia time was added for the preoperative embolization procedure (range, 94-104 min). All patients had a successful embolization without need for coils. Operative time ranged from 28 to 44 min for the simple cases and was 6 h and 30 min for the complex case. There was minimal blood loss in all cases. There were no associated complications, lesion recurrences, or long-term deficits at an average follow-up of 5 months. The patient with the complex hemifacial VM demonstrated subtle lower facial weakness post-operatively, which completely resolved within two months. CONCLUSIONS Treatment of head and neck vascular malformations with preoperative n-BCA glue and subsequent surgical excision is a viable method for both simple and complex lesions. The safety and efficacy of this technique has been demonstrated in the past in a limited number of studies. This study further supports the use of this technique to address patient concerns such as pain or discomfort and cosmetic deformity, even if the lesion is only partially resectable. In our series a lymphatic malformation refractory to sclerotherapy was treated with a similar technique of glue and resection, following aspiration of the mucoid LM fluid. Our series emphasizes that pediatric vascular malformations carry functional and cosmetic deficits into adulthood that can and should be addressed in this patient population. Therefore, same-day embolization and resection should be coordinated when possible, in order to optimize patient safety and convenience.
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Affiliation(s)
- Ryan Puccia
- Medical College of Wisconsin Department of Otolaryngology, United States.
| | - Kelly Staricha
- Medical College of Wisconsin Department of Otolaryngology, United States
| | | | - David Moe
- Medical College of Wisconsin Department of Radiology, United States
| | - Robert Chun
- Medical College of Wisconsin Department of Otolaryngology, United States.
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9
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Abstract
The head and neck are the most common site of involvement for vascular tumors and malformations, with more than half of all vascular anomalies seen in this region. Lesions in this location can cause significant disfigurement and can be associated with airway obstruction, impairment in vision or hearing, swallowing disorders and hemorrhage. Accurate diagnosis is critical in determining treatment, and interdisciplinary care is essential for optimal management. We review clinical and imaging features that are key to establishing the correct diagnosis, and review treatment modalities, with emphasis on interventional and surgical procedures.
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Affiliation(s)
- Abdullah Alsuwailem
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, USA
| | - Charles M Myer
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Gulraiz Chaudry
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, USA.
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10
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Polites SF, Watanabe M, Scorletti F, Patel MN, Ricci KW, Hammill AM, Dasgupta R. Single-stage embolization with n-butyl cyanoacrylate and surgical resection of venous malformations. Pediatr Blood Cancer 2020; 67:e28029. [PMID: 31749319 DOI: 10.1002/pbc.28029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/10/2019] [Accepted: 09/07/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE Sclerotherapy or surgical resection is options for symptomatic venous malformations (VM). Sclerotherapy may require repetitive intervention and resection is often avoided due to operative morbidity. The purpose of this study was to report use of single-stage n-butyl cyanoacrylate glue embolization and surgical resection of focal VM. METHODS A review of patients with focal VM who underwent glue embolization followed by resection at a single tertiary care vascular malformations center was performed. All embolizations were performed with ultrasound and fluoroscopy under the same anesthetic as resection. Patient characteristics and outcomes were evaluated. RESULTS Fifteen procedures were performed in 12 patients with a total of 20 VM addressed, as several patients had multiple VM. Mean age was 16 ± 9 years. Malformation locations included scalp, hip, gluteal, labial, toe, finger, face, lip, chest, and foot and size ranged from 1.0 to 10.5 cm. Median (range) of prior sclerotherapy treatments was 3 (0-5) and three patients previously underwent surgical resection. Median blood loss was zero (0-10) mL. Surgical complications occurred after five procedures (33%) including superficial wound dehiscence and cellulitis. No complications required readmission or reoperation. At a median follow up of 195 (103-266) days, no patients have required additional treatment. CONCLUSION Glue embolization and resection of focal VM of variable size and location appears to have durable results and low surgical morbidity. This single-stage procedure, often performed as an outpatient, may be utilized as upfront treatment for symptomatic malformations or for VM refractory to other treatments.
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Affiliation(s)
- Stephanie F Polites
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Miho Watanabe
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Federico Scorletti
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Manish N Patel
- Division of Interventional Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kiersten W Ricci
- Division of Hematology, Cancer and Blood Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adrienne M Hammill
- Division of Hematology, Cancer and Blood Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Roshni Dasgupta
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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11
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Gnannt R, Guggenberger R, Mueller DA, Neuhaus K, Aufdenblatten C, Theiler M, Kellenberger CJ, Pfammatter T. MR Features of Juxta-Articular Venous Malformations of the Knee to Predict the Clinical Outcome of Sclerotherapy. J Vasc Interv Radiol 2019; 31:551-557. [PMID: 31882302 DOI: 10.1016/j.jvir.2019.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/17/2019] [Accepted: 11/13/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To analyze and correlate preinterventional magnetic resonance (MR) imaging findings with clinical symptoms after percutaneous sclerotherapy of venous malformations (VMs) adjacent to the knee. MATERIALS AND METHODS Twenty-five patients (mean age, 24 y; range, 7-55 y; 11 female) with 26 VMs adjacent to the knee undergoing sclerotherapy (direct puncture, diagnostic angiography, sclerosant injection) were identified, and MR imaging findings were analyzed. The VM involved the synovium of the knee joint in 19 of 26 cases (76%). These lesions were associated with joint effusion (3 of 19; 16%), hemarthrosis (4 of 19; 21%), or synovial thickening (16 of 19; 84%). Follow-up ended 6-8 weeks after the first or second sclerotherapy session if complete pain relief was achieved or 3 months after the third sclerotherapy session. Treatment outcomes were categorized as symptom improvement (complete or partial pain relief) or poor response (unchanged or increased pain). RESULTS Forty-nine percutaneous sclerotherapy sessions were performed. Despite the absence of signs of knee osteoarthritis, patients with a VM involving the synovium (8 of 14; 57%) showed a poor response to sclerotherapy (1 of 8 [13%] pain-free after 1 sclerotherapy session). Among patients with VMs with no associated joint alteration and no synovial involvement (6 of 14; 43%), 5 of 6 (83%) showed improvement of symptoms after 1 sclerotherapy session (P < .05). CONCLUSIONS Juxta-articular VMs of the knee are frequently associated with hemarthrosis and synovial thickening. Patients with signs of osteoarthritis and synovial involvement of the VM on presclerotherapy MR imaging deserve special consideration, as these findings predict worse clinical symptoms after sclerotherapy.
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Affiliation(s)
- Ralph Gnannt
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland; Department of Diagnostic Imaging, University Children's Hospital Zurich, Steinwiesstrasse 75, CH 8032 Zurich, Switzerland.
| | - Roman Guggenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel A Mueller
- Department of Orthopaedics, Der Balgrist-Universitätsklinik, Zurich, Switzerland
| | - Kathrin Neuhaus
- Division of Plastic and Reconstructive Surgery and Department of Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, CH 8032 Zurich, Switzerland
| | - Christoph Aufdenblatten
- Departments of Orthopaedics and Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, CH 8032 Zurich, Switzerland
| | - Martin Theiler
- Division of Pediatric Dermatology, University Children's Hospital Zurich, Steinwiesstrasse 75, CH 8032 Zurich, Switzerland
| | - Christian J Kellenberger
- Department of Diagnostic Imaging, University Children's Hospital Zurich, Steinwiesstrasse 75, CH 8032 Zurich, Switzerland
| | - Thomas Pfammatter
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
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12
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Abstract
Vascular anomalies encompass a wide variety of clinical conditions involving the vasculature. Over the past several decades, the terminology has changed as our understanding of these conditions has improved. A well-accepted classification scheme has evolved with constant additions, updates, and revisions. Imaging techniques have also advanced with greater resolution and a better understanding of the correlation between imaging, clinical behavior, and natural history. Meanwhile, the treatment of these conditions has also changed, with greater focus on minimally invasive techniques as opposed to radical surgery. Despite these changes, surgical intervention remains a high-value option for select patients. With greater understanding of the molecular basis of these diseases, medical treatment has improved especially in severe cases where options remain limited. A multidisciplinary approach to comprehensive patient care usually yields the best outcome and is strongly encouraged.
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Affiliation(s)
- Amir H Taghinia
- Department of Plastic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Joseph Upton
- Department of Plastic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
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13
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Arteriovenous Malformations: Syndrome Identification and Vascular Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:67. [PMID: 30019284 DOI: 10.1007/s11936-018-0662-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW Vascular malformations represent a poorly understood set of conditions that create considerable diagnostic and therapeutic confusion. Historically, extensive surgical resections yielded poor results. More recently, the treatment paradigm has shifted to endovascular therapy such that embolization and sclerotherapy are now considered the first line of treatment. Although there is still a role for traditional surgical techniques, it is now most commonly integrated with endovascular therapies in a hybrid fashion. The goal of this review is to provide a greater understanding of the diagnosis and treatment of vascular malformations. RECENT FINDINGS Vascular malformations can be high-flow (arteriovenous shunting) or low-flow (venous or lymphatic). Clinical presentation and treatment is different for each. Treatment of high-flow lesions must be directed at reducing or eliminating the nidus, usually via super-selective catheterization and embolization. Low-flow lesions are usually treated by direct injection of sclerosing agents under fluoroscopic or ultrasound guidance. The cornerstone of managing patients with vascular malformations is making the proper diagnosis, which is often challenging. Even after a diagnosis is made, therapy itself may be challenging and generate frustration among patients and providers. Frequently, the treatment of vascular malformations is characterized by only slow and incremental improvements without complete lesion eradication. By combining a thorough understanding of the vascular malformation disease process with an array of endovascular techniques, vascular interventionalists may contribute greatly to the care of these patients.
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