Venous malformations: clinical diagnosis and treatment

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.

Safety and efficacy of cryoablation of soft-tissue tumours: a systematic review

OBJECTIVES

To assess the safety and efficacy of percutaneous cryoablation (CA) of soft-tissue tumours [desmoid tumours (DTs), vascular malformations (VMs), and abdominal wall endometriosis (AWE)].

METHODS

This systematic review of studies published before January 2024 encompassed a detailed analysis of CA techniques and technical aspects for the treatment of soft-tissue tumours. Data concerning CA efficacy, complication rates, and other relevant metrics were extracted and included for analysis.

RESULTS

The analysis included 27 studies totalling 554 CA procedures. For DT (13 studies, 393 sessions), CA showed an average pain reduction of 79 ± 17% (range: 57-100) and a lesion volume decrease of 71.5 ± 9.8% (range: 44-97). VM (4 studies, 58 sessions) had a 100% technical success rate and an average pain reduction of 72 ± 25% (range: 63-85). The average pain reduction for AWE (6 studies, 103 sessions) was 82 ± 13% (range: 62-100). Overall, the complication rate for CA was low, with minor adverse events (AEs) in about 20% of patients and major events in less than 5% of patients.

CONCLUSIONS

Showing substantial efficacy in pain reduction and lesion volume decrease, as well as low incidence of severe AE, CA presents as a highly effective and safe alternative for the treatment of soft-tissue tumours.

ADVANCES IN KNOWLEDGE

CA is effective and safe in treating soft-tissue tumours, particularly DT, VM, and AWE.

Room utilization analysis of pre-operative glue embolization for venous malformations: procedure times and outcomes

BACKGROUND

Pre-operative n-butyl-2-cyanoacrylate embolization and surgical resection is an established treatment for venous malformations. A single-session treatment is optimal but requires accurate procedural time estimates for the interventional radiology and surgical portions of the treatment to optimize coordination. Understanding the variables affecting room time could improve coordination, raise efficiency, and eventually help to estimate cost for patients.

OBJECTIVE

Identify which factors have a significant impact on the room time for pre-operative glue embolization of venous malformations.

MATERIALS AND METHODS

A single institution, institutional review board-approved, retrospective study of glue embolization procedures was performed over an 8-year period. The impacts of patient, operator, technical factors, and malformation characteristics on procedure time and room time were analyzed using univariate and multivariate log-transformed linear mixed models to account for data skewedness.

RESULTS

A total of 232 patients were identified with a median age of 13 years (IQR, 8.5; 16 years) and median weight of 48 kg (IQR, 27; 64 kg). Higher Puig's classification number (β range, -0.04-0.41; P=0.02), larger malformation dimension (β=0.0031; P<0.001), use of cone beam CT (β=0.29; P<0.001), and the presence of adverse events (β=0.54; P<0.001) significantly increased procedure time on multivariate analysis. The presence of an adverse event (β=0.3100; P<0.001), use of cone beam CT utilization (β=0.1600; P<0.001), and larger venous malformation dimension (β=0.0017; P<0.001) significantly lengthened total room time. The performing physician additionally impacted both total room times (P<0.001); however, the experience level with glue embolization varied significantly between providers (P<0.001) and was felt to be a contributing factor.

CONCLUSION

The room time required for n-butyl-2-cyanoacrylate embolization prior to venous malformation resection is significantly dependent on the presence of complications, cone beam CT use, malformation size, and performing physician experience.

Natural progression and early recurrence of venous malformations following surgical and endovascular treatments: A 15-year retrospective cohort study

BackgroundVenous malformations (VMs) are the most common type of vascular malformation. Recurrence after treatment remains a significant challenge in clinical management.MethodsA multi-center retrospective cohort study was conducted on consecutive patients who received surgical or endovascular VM treatment from 2005 to 2020. The study aimed to compare treatment efficacy between surgical and non-surgical endovascular approaches. Post-treatment size, symptoms, and recurrence were evaluated more than 1 year after treatment.ResultsNinety-eight patients with 288 VM treatment cases were included. The mean follow-up duration was 60.7 ± 42.4 months. Both surgical and non-surgical treatments showed size improvement and symptom improvement in more than 90% and 75% of the cohort, respectively. Regarding recurrence, patients who underwent total resection (26.5%; p < .001) and primary closure (44.6%; p = .04) had significantly lower recurrence rates among the whole cohort.ConclusionWhere feasible, total resection is the ideal treatment modality. Sclerotherapy has a higher long-term recurrence rate but is a less invasive procedure that can be performed repeatedly.

Optimizing treatment selection in venous malformations through imaging-assisted sequential therapy: a case series analysis

OBJECTIVE

Venous malformations (VMs) are the most prevalent slow-flow congenital vascular anomalies. Effective management of VMs often necessitates individualized approaches, particularly for lesions with significant interstitial components. This study aims to evaluate a sequential treatment strategy combining sclerotherapy and open surgery, with guidance from ultrasound (US) and magnetic resonance imaging (MRI).

METHODS

A retrospective analysis was performed on a case series of 10 patients with VMs. Each patient underwent initial sclerotherapy, followed by surgical intervention. Preoperative US and MRI were used to assess treatment progress and optimize the timing of surgery.

RESULTS

Sclerotherapy effectively reduced the venous components of VMs by inducing fibrosis, which diminished blood supply and facilitated subsequent surgical excision. Sequential plastic surgical resection successfully removed the interstitial components, further improving outcomes, particularly in cosmetically sensitive areas. Imaging modalities played a key role in monitoring the treatment process; US was effective for superficial lesions, whereas MRI provided essential insights into deeper and more complex malformations.

CONCLUSIONS

Sequential treatment, incorporating preoperative sclerotherapy and tailored surgical planning, is essential for the effective management of VMs. Further research with larger, multicenter studies is needed to validate these findings and optimize treatment protocols.

In-human clinical experience with direct stick embolization of low-flow vascular malformations using a mammalian target of rapamycin inhibitor

BACKGROUND

Although direct stick embolization (DSE) of low-flow vascular malformations (LFVMs) with off-label embolotherapeutic compounds is the current mainstay of therapy, systemic oral mammalian target of rapamycin (mTOR) inhibition has evolved into an important adjunctive therapy that is associated with frequent blood draws, systemic toxicity, and rebound signs and symptoms upon cessation. We herein report our experience with in-human DSE of LFVMs with an mTOR inhibitor for direct, intralesional targeting of the culprit mutated pathway without repeated systemic exposure.

METHODS

Since 2020, 33 procedures involving DSE were performed in 25 patients with LFVMs using a patented formulation and technique involving the intravenously compatible mTOR inhibitor Yale-OCR7737, used as a liquid compound in a collagen matrix emulsion for added viscosity and intralesional residence. Data were maintained prospectively and reviewed retrospectively for technical success (successful catheterization of the lesion and intralesional delivery of compound), clinical success (improvement in signs/symptoms with radiologically documented reduction in flow and/or volume of treated lesion), complications, side effects, and reinterventions.

RESULTS

From 2020 to 2023, 33 procedures involving DSE were performed using Yale-OCR7737 in 25 patients (10 men [40%]; 15 women [60%]; mean age, 28 years [range, 1-70 years]) with LFMVs involving the head/neck (48%) and limbs (40%); 88% were nonsyndromic and 12% had Klippel-Trenaunay syndrome; 68% exhibited venous malformations, and 32% had lymphatic malformations. Technical and clinical success rates were 100%. Mean DSE sessions per patient was 1.4 (range, 1-5). Localized intravascular coagulopathy was present after 16 DSE procedures (49%); D-dimer improved after DSE in 7 cases. No perioperative or delayed complications occurred. Side effects were seven cases (21%) of self-limited, transient, oral aphthous ulcers.

CONCLUSIONS

Our findings suggest that DSE of LFVMs with mTOR inhibitors (Yale-OCR7737) may be safe and effective. This may represent the new embolotherapeutic frontier in the endovascular treatment of LFMVs.

Generation of iPSC-derived human venous endothelial cells for the modeling of vascular malformations and drug discovery

Venous malformations (VMs) represent prevalent vascular anomalies typically attributed to non-inherited somatic mutations within venous endothelial cells (VECs). The lack of robust disease models for VMs impedes drug discovery. Here, we devise a robust protocol for the generation of human induced VECs (iVECs) through manipulation of cell-cycle dynamics via the retinoic signaling pathway. We introduce an L914F mutation into the TIE2 gene locus of induced pluripotent stem cells (iPSCs) and show that the mutated iVECs form dilated blood vessels after transplantation into mice, thereby recapitulating the phenotypic characteristics observed in VMs. Moreover, utilizing a deep neural network and a high-throughput digital RNA with perturbation of genes sequencing (DRUG-seq) approach, we perform drug screening and demonstrate that bosutinib effectively rescues the disease phenotype in vitro and in vivo. In summary, by leveraging genome editing and stem cell technology, we generate VM models that enable the development of additional therapeutics.

Spongiform Venous Malformation Presenting as an Extensive Lesion in the Gluteal Region

Venous malformations (VMs) are vascular malformations affecting a small portion of the population. A 53-year-old woman presented with a congenital VM on the left gluteal region confirmed through clinical imaging and histopathology. Treatment with sclerotherapy led to significant improvement. VMs often cause pain, swelling, or mobility limitations. Diagnosis relies on Doppler ultrasound and MRI, while sclerotherapy is the preferred treatment due to its safety and efficacy. This case highlights sclerotherapy as a key treatment in a multidisciplinary management approach.

Management options for vascular anomalies in the distal extremities

Vascular anomalies arise during embryologic development due to errors in vasculogenesis. They are associated with sporadic or inherited mutations in receptors, growth factors or enzymes within various vasculogenic pathways such as mTOR, VEGF, and PI3K. Vascular anomalies have the capability to cause significant symptoms and disability, especially when located in the distal extremities. These symptoms often include local pain, swelling, and decreased range of motion and functionality of the affected area. This article intends to provide a concise overview of vascular anomalies in the distal extremities and their treatment options. The categorization of the vascular anomalies, key clinical features, diagnostic approaches, and potential significance of when they occur in the extremities and how that makes them unique are discussed. An overview of the six major management options used to treat vascular anomalies in general is reviewed in the context of vascular anomalies in the extremities, including observation, pharmacotherapy, sclerotherapy, embolization, cryoablation, and surgery. Each section discusses the role of the treatment approach and associated benefits and risks.

Vascular lesions: Hemangioma or venous malformation?

We present a case of a 62-year-old female who was incidentally found to have a venous malformation. Venous malformations are part of a larger category of slow flow vascular malformations and are associated with various familial syndromes and localized intravascular coagulation. Venous malformations were often misdiagnosed as hemangiomas; however, the treatment modalities of vascular malformations and hemangiomas vary significantly. Here we elucidate the imaging findings of venous malformations from various vascular tumors and other malformations.

Nd:YAG Laser Treatment of Massive Tongue Venous Malformation: A Case Report

Venous malformations (VM) are slow-flow vascular lesions that result from morphogenesis errors. Composed of dysfunctional veins lacking smooth muscle cells, VMs grow slowly and may initially be managed by observation. Treatment is indicated for lesions that cause functional impairment. One treatment option is laser therapy, which is very effective due to its tissue penetration and relative selectivity. The Nd:YAG laser has been shown to treat small and moderately sized mucosal vascular lesions; in this case, it was applied in a staged approach for treatment of a massive venous malformation of the tongue. A 66-year-old male presented with a venous malformation involving the tongue and lower lip, the lesion estimated to be 10 x 14 x 15 cm in size. The Nd:YAG laser was used in three separate stages to photocoagulate the venous lesion. Follow-up for recurrence is ongoing, but currently shows complete malformation ablation with a 36.2% volume reduction after treatment. The Nd:YAG laser is an effective tool in the treatment of large vascular lesions. Successful laser application in a staged approach for the treatment of a venous malformation of this size and complexity further supports its clinical value. Monitoring for possible recurrence of the venous malformation should be ongoing.

Enhanced sclerotherapy for vascular malformations: A dual-mechanism approach using in-situ forming PATDs gel

Vascular malformations are common vascular lesions in infants and seriously affect their health and quality of life. Vascular sclerotherapy is an effective treatment for vascular malformations. However, current sclerosants have difficulty achieving both high efficiency and low toxicity, and their dosing forms make it difficult to achieve long-term retention in the affected blood vessels. Therefore, exploring a safe and effective sclerosant and its delivery strategy is the key to clinical sclerotherapy. To address the above issues, this study developed sclerosants that could form an in-situ gel based on a dual mechanism of vascular injury and plasmin (PLA) inhibition. By linking the non-ionic surfactant sclerosant polyoxyethylene alkyl ether (PAs) and the PLA inhibitor tranexamic acid (TA) through an ester bond, a cationic surfactant sclerosant polyoxyethylene alkylether tranexamate derivatives (PATDs) were constructed. The cationic charge of PATDs enhanced its cytotoxicity to HUVEC-TIE2-L914F cells, and the ester bond of PATDs could be degraded by esterase in the blood, reducing its systemic toxicity. The degradation product TA inhibited the activation of the PLA-matrix metalloproteinase (MMPs) system induced by vascular injury, thereby promoting the deposition of collagen and the proliferation and differentiation of fibroblasts to promote vascular fibrosis. In addition, an injectable solution (PATDs/GA) was prepared by mixing PATDs with glycerol formaldehyde (GA), and PATDs/GA could form a low-molecular-weight gel automatically in an aqueous solution, which was beneficial to increase its retention in the affected blood vessels and reduce the risk of drug entering non-targeted sites. At the same time, this gel automatically dissolved, reducing the risk of immune rejection caused by long-term retention. This study provided a new and precise approach for the treatment of vascular sclerosis with high efficiency and low toxicity.

Cationic amphiphilic molecules as novel sclerosants for venous malformation treatment: A study on tranexamic acid-derived low-molecular-weight gels

Venous malformation (VM) is a prevalent congenital vascular anomaly characterized by abnormal blood vessel growth, leading to disfigurement and dysfunction. Sclerotherapy, a minimally invasive approach, has become a primary therapeutic modality for VM, but its efficacy is hampered by the rapid dilution and potential adverse effects. In this study, we introduced a series of cationic amphiphilic molecules, fatty alcohol esters (TA6, TA8, and TA9) of tranexamic acid (TA), which self-assembled into low-molecular-weight gels (LMWGs) in water. The TA9, in particular, is released slowly when hydrogel is injected into the vein locally. Then, it damages the venous wall by destroying cell membranes and precipitating proteins, causing inflammation and thrombosis, thickening of the venous wall, effectively inducing irreversible vein fibrosis. Additionally, TA9 can be rapidly degraded into TA in plasma to reduce toxicity caused by diffusion. Overall, this study suggests that the cationic amphiphilic molecule TA9 is a promising sclerosant for VM treatment, offering a novel, effective, and safe therapeutic option with potential for clinical translation.

Single-session Preoperative Embolization and Surgical Resection of Vascular Anomalies: A Case Series

Vascular anomalies encompass 2 broad classifications including vascular tumors and vascular malformations. The management of vascular anomalies is best approached by a multidisciplinary team. Surgical treatment can offer definitive treatment, but carries several risks such as intraoperative hemorrhage, recurrence, and collateral vascular formations from incomplete resections. Here, we present a case report of 3 patients with different vascular anomalies who were all treated by a multidisciplinary team including interventional radiology and plastic surgery. All underwent preoperative embolization before surgical excision, accomplished under a single anesthetic. Here, we discuss the surgical planning and overall approach to patients presenting with localized vascular anomalies and support the use of preoperative embolization with surgical excision under a single anesthetic as a treatment approach.

Successful Treatment of Low-Flow Vascular Malformation in the Lip Using Intralesional Bleomycin: A Case Report

Vascular malformations (VMs) are congenital abnormalities of blood or lymphatic vessels, present at birth and growing proportionally with the individual. They are classified into types such as capillary, venous, lymphatic, and arteriovenous malformation (AVMs). Symptoms include discoloration, swelling, pain, or functional impairment, depending on the type and location. Diagnosis involves imaging like ultrasound, MRI, or angiography, and treatment options include sclerotherapy, laser therapy, embolization, or surgery for symptomatic cases. It is a class of vascular anomalies, known as VMs are benign lesions that arise from aberrant vascular tissue and can result from either lymphatic proliferation or angiovascular dysregulation. High-flow VMs, such as AVMs, involve direct connections between arteries and veins. AVMs can be congenital, presenting at birth. They are typically persistent and progressive, with the potential to cause significant blood loss, which can be life-threatening. Several treatment modalities are available, including surgical excision, electrocautery, LASER therapy, cryotherapy, radiotherapy, and the use of locally injected agents. Among these, sclerosing agents are particularly advantageous due to their affordability, availability, and high efficacy. Commonly used sclerosing agents include ethanol, sodium morrhuate, sodium tetradecyl sulfate (STS), boiling contrast media, and bleomycin. This case report describes a VM with low-flow characteristics located at the commissure of the lip, which was successfully treated with intralesional bleomycin injections. The aim of this case report is to document the successful management of a low-flow VM at the lip commissure using intralesional bleomycin injections. It highlights the efficacy and safety of this minimally invasive treatment in achieving favorable cosmetic and functional outcomes. The study also seeks to contribute to the growing evidence supporting sclerotherapy as a reliable alternative to surgical intervention.

Retrospective clinical study on the efficacy and complications of interventional embolization in the treatment of scalp arteriovenous fistula

Introduction

Scalp arteriovenous fistula (AVF) is a rare and intricate vascular anomaly characterized by a direct connection between an artery and a vein, without an intervening capillary system. This anomaly can induce significant local hemodynamic changes and is associated with various complications, such as pain, a pulsatile mass, increasing swelling, and venous hypertension skin ulcerations which may be non-healing. This study aimed to evaluate the efficacy and safety of interventional embolization treatments for scalp AVF at Shandong Provincial Hospital.

Methods

This retrospective clinical analysis assessed 21 patients who underwent interventional embolization between 2018 and 2024. Patients included were those treated in the vascular surgery department at Shandong Provincial Hospital, who had comprehensive medical records and follow-up data. Treatment methods, outcomes, and complications were thoroughly analyzed through patient medical records.

Results

Among the patients studied, direct puncture was the most prevalent treatment method, employed in 42.86% (9/21) of cases, followed by various combinations of arterial, venous, and direct approaches. Ethanol, used in 85.71% (18/21) of the cases, demonstrated its broad efficacy and application in clinical settings. Immediate imaging post-treatment confirmed a cure rate of 85.71% (18/21). The main postoperative complications included swelling, with some patients also experiencing nodules, scabbing, or hair loss.

Conclusion

Interventional embolization has proven to be a safe and effective method for managing scalp AVF, significantly minimizing complications. Future research should focus on further optimizing these treatment methods to enhance efficacy and improve patient quality of life.

Anatomical variations of the external jugular veins and collaterals incidentally diagnosed with computed tomography in Shih Tzu dogs

Introduction

The external jugular vein (EJV) is a superficial vein of the neck in dogs; its significance is evident in veterinary clinical practice, encompassing surgeries and interventional procedures. However, there have been no reports on EJV variations in canines, despite extensive studies on variations in the jugular veins in humans. This study aimed to use CT imaging to evaluate the prevalence of anatomic vascular variations of the EJVs in Shih Tzu dogs and to describe the clinical and CT characteristics of these vascular variants.

Methods

This is a retrospective, multi-center study. The medical imaging records of Shih Tzu dogs that underwent pre- and post-contrast CT examinations of the head, neck, and thorax at the Veterinary Medical Teaching Hospital, Konkuk University, and 10 referral hospitals between 2015 and 2023 were reviewed.

Results

We defined five types of EJV vascular variants: normal (type I), unilateral hypoplasia (type II), unilateral aplasia (type III), bilateral hypoplasia (type IV), and bilateral aplasia (type V), based on the morphological and diameter differences observed in the transverse images of Shih Tzu dogs. CT images from 547 Shih Tzu dogs revealed 119 cases (21.7%) of EJV variants. Type I was observed in 428 dogs (78.2%), type II in 46 dogs (8.4%), type III in 41 dogs (7.5%), type IV in 14 dogs (2.6%), and type V in 18 dogs (3.3%). In types II-V, compensatory drainage through the internal jugular vein (IJV) was observed, often involving the medial passage of the maxillary or linguofacial veins. A moderate negative correlation (R = -0.5) was recorded between the hypoplastic EJV and the affected-side IJV (p < 0.01). Some cases exhibited other supplementary drainage routes, such as the hyoid venous arch or median thyroid vein. Additionally, 63 persistent left cranial vena cava (PLCVC) cases (11.9%) were identified among 529 Shih Tzu dogs, showing a significant association with EJV abnormalities (p < 0.05).

Discussion

Overall, this study identified anatomical variants of the EJV in Shih Tzu dogs and introduced a new classification system. These findings revealed that EJV variants and compensatory tributary enlargement were more prevalent than previously recognized, emphasizing the need to consider these nuances in veterinary procedures and imaging.

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.

Correlation between the miR-618 rs2682818 C>A polymorphism and venous malformation susceptibility

Venous malformations are the most common congenital vascular malformations, and the incidence rate is high. Previous studies have confirmed that a variety of polymorphisms within the miRNA functional region are associated with tumor susceptibility. We examined the correlation between miR-618 rs2682818 C>A and risk of developing venous malformation in a southern Chinese population (1113 patients and 1158 controls). TaqMan genotyping of miR-618 rs2682818 C>A was conducted utilizing real-time fluorescent quantitative PCR. The miR-618 rs2682818 polymorphism was not correlated with susceptibility to venous malformation (CA/AA vs. CC: adjusted odds ratio [AOR] = 1.00, 95% confidence interval [CI] = 0.81-1.25, p = 0.994; AA vs. CC/CA: AOR = 1.10, 95% CI = 0.73-1.65, p = 0.646). Stratified analysis of different subtypes of venous malformation revealed that there was no significant difference in the rs2682818 C>A polymorphism genotypes across these subtypes. Our results indicate that miR-618 rs2682818 C>A polymorphism is not correlated with the susceptibility to venous malformation.

Intramuscular Venous Malformation Associated with Muscle Herniation of the Left Masseter Muscle in a 12-Year-Old Boy

BACKGROUND Muscle hernias are an uncommon condition typically found in the extremities; masseter muscle hernia is even rarer. However, it is important for clinicians and radiologists to be aware of this possibility. Intramuscular venous malformation (IMVM) is also uncommon and mostly found in the head, neck, and extremities. The simultaneous presence of both conditions is extraordinary uncommon, and, to our knowledge, this has not been reported before in the masseter muscle. Due to their rarity, vague presentation, and inaccurate clinical diagnosis, radiological evaluation is needed to avoid inappropriate surgical planning. CASE REPORT A 12-year-old boy had a long-standing focal left cheek swelling exacerbated by teeth clenching. Lateral X-ray revealed a round calcification over the left mandibular region. Ultrasonography indicated a bulky left masseter muscle with focal heterogeneous structure and 2 rounded calcified foci. During teeth clenching, ultrasonography detected focal muscular herniation through the left masseter muscle facia that reduced with rest. The patient was diagnosed with left masseteric muscle hernia coexistent with IMVM. Surgical excision of the IMVM was performed, and the hernia defect was repaired. Histopathology confirmed the diagnosis, and the patient was discharged without postoperative complications on short-term follow-up. CONCLUSIONS Despite their rarity, masseter hernias and IMVMs should be considered in the differential diagnosis of any masseter lesion, especially in children. We reported a very rare coexistence of both pathologies. Comprehensive diagnosis can be achieved through a combination of clinical examination, X-ray, and ultrasound assessments.

A calvarial osteolytic lesion of probable vascular origin in a Maya juvenile from the Classic Period ( 250-900 CE)

OBJECTIVE

This case study evaluates a focal osteolytic lesion in the right sulcus sinus transversi of an isolated os occipitale.

MATERIALS

The os occipitale is from a juvenile from the Cueva de Sangre at the Classic Period (250-900 CE) site of Dos Pilas, Guatemala METHODS: The lesion was examined macroscopically, microscopically, and radiographically.

RESULTS

The oval lesion has a well-circumscribed margin, endocranial origin, and involves cortical destruction of the inner and outer tables. Subperiosteal bone reaction around the lesion is present on the ectocranial surface. Skeletal evidence of increased vascularity, diploë expansion, and perimortem fracture near the lesion are not observed.

CONCLUSIONS

The lesion appears to reflect a response to the presence of an expansile process that has caused pressure erosion. The anatomical location of the lesion and the endocranial origin suggest a probable vascular anomaly, such as a vascular malformation.

SIGNIFICANCE

This case study represents one of the few bioarchaeological evaluations of probable vascular anomaly in a juvenile. As such, it expands our knowledge about vascular anomalies in the past and provides a comparative and core reference for guiding future paleopathological investigations on cranial osteolytic lesions.

LIMITATIONS

The skeletal assemblage is commingled and fragmentary preventing the assessment of the distribution of lesions across the skeleton.

SUGGESTIONS FOR FUTURE RESEARCH

Further scrutiny of bioarchaeological collections is needed to better understand the distribution of vascular anomalies in the past.

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.

Imaging of Vascular Anomalies

Vascular anomalies (VAs) are a heterogeneous group of vascular malformations and tumors that are frequently encountered in daily practice. While most are benign, malignant vascular tumors exist, as do other nonvascular soft-tissue malignancies that may masquerade as a benign VA. The subtleties of arriving at an accurate diagnosis can be intimidating, as new entities are described and names of conditions have been modified. Therefore, the goal of this article is to describe the classic imaging findings of VAs so that the interventional radiologist can confidently and competently contribute to management decisions, with special attention to ominous imaging features that should prompt biopsy or further imaging workup.

Enhancing Trauma Care: A Machine Learning Approach with XGBoost for Predicting Urgent Hemorrhage Interventions Using NTDB Data

OBJECTIVE

Trauma is a leading cause of death worldwide, with many incidents resulting in hemorrhage before the patient reaches the hospital. Despite advances in trauma care, the majority of deaths occur within the first three hours of hospital admission, offering a very limited window for effective intervention. Unfortunately, a significant increase in mortality from hemorrhagic trauma is primarily due to delays in hemorrhage control. Therefore, we propose a machine learning model to predict the need for urgent hemorrhage intervention.

METHODS

This study developed and validated an XGBoost-based machine learning model using data from the National Trauma Data Bank (NTDB) from 2017 to 2019. It focuses on demographic and clinical data from the initial hours following trauma for model training and validation, aiming to predict whether trauma patients require urgent hemorrhage intervention.

RESULTS

The XGBoost model demonstrated superior performance across multiple datasets, achieving an AUROC of 0.872 on the training set, 0.869 on the internal validation set, and 0.875 on the external validation set. The model also showed high sensitivity (77.8% on the external validation set) and specificity (82.1% on the external validation set), with an accuracy exceeding 81% across all datasets, highlighting its high reliability for clinical applications.

CONCLUSIONS

Our study shows that the XGBoost model effectively predicts urgent hemorrhage interventions using data from the National Trauma Data Bank (NTDB). It outperforms other machine learning algorithms in accuracy and robustness across various datasets. These results highlight machine learning's potential to improve emergency responses and decision-making in trauma care.

Gene expression profiling of venous malformations identifies the role of SDC1 in venous endothelial cells

Objective

To obtain insight into the molecular process implicated in venous malformations (VMs) and identify potential targets for treatment of VMs, this study profiled the gene expression pattern in VMs, investigated alterations of syndecan-1 (SDC1) expression in VMs, and tested the hypothesis that aberrant SDC1 expression triggers abnormal angiogenesis and VM development.

Methods

Microarray analysis was performed to identify differentially expressed genes (DEGs) on a transcriptome-wide level in VMs and conjunctive normal. Gene Ontology molecular functional analysis and Kyoto Encyclopedia of Genes and Genomes pathway analysis were carried out to establish enhancement of biological signaling pathways involved in VMs. Among the DEGs, we focused on SDC1, which is involved in matrix remodeling, cell proliferation and invasion, and angiogenesis. SDC1 expression in VMs was verified by qRT-PCR, western blotting, and immunohistochemistry. Loss-of-function of SDC1 was achieved in human umbilical vein endothelial cells (HUVECs) by siRNA to investigate the roles of SDC1 in cell migration, invasion, and angiogenesis.

Results

Compared with control tissue, the transcriptome study identified 274 upregulated DEGs and 3 downregulated DEGs. The transcript and protein levels of SDC1 were significantly decreased in VMs compared with normal tissue. Inhibition of SDC1 enhanced HUVEC migration, invasion, and angiogenesis.

Conclusion

Our genome-wide microarray analysis suggests the involvement of numerous genes in VMs. Among them, SDC1 plays a substantial role in the process of angiogenesis and development of VMs. SDC1 may represent a potential target for a molecular therapy for VMs.

Congenital Vascular and Lymphatic Diseases

Over the past several centuries, the integration of contemporary medical techniques and innovative technologies, like genetic sequencing, have played a pivotal role in enhancing our comprehension of congenital vascular and lymphatic disorders. Nonetheless, the uncommon and complex characteristics of these disorders, especially considering their formation during the intrauterine stage, present significant obstacles in diagnosis and treatment. Here, we review the intricacies of these congenital abnormalities, offering an in-depth examination of key diagnostic approaches, genetic factors, and therapeutic methods.

Targeted therapy for capillary-venous malformations

Sporadic venous malformations are genetic conditions primarily caused by somatic gain-of-function mutation of PIK3CA or TEK, an endothelial transmembrane receptor signaling through PIK3CA. Venous malformations are associated with pain, bleedings, thrombosis, pulmonary embolism, esthetic deformities and, in severe cases, life-threatening situations. No authorized medical treatment exists for patients with venous malformations. Here, we created a genetic mouse model of PIK3CA-related capillary venous malformations that replicates patient phenotypes. We showed that these malformations only partially signal through AKT proteins. We compared the efficacy of different drugs, including rapamycin, a mTORC1 inhibitor, miransertib, an AKT inhibitor and alpelisib, a PI3Kα inhibitor at improving the lesions seen in the mouse model. We demonstrated the effectiveness of alpelisib in preventing vascular malformations' occurrence, improving the already established ones, and prolonging survival. Considering these findings, we were authorized to treat 25 patients with alpelisib, including 7 children displaying PIK3CA (n = 16) or TEK (n = 9)-related capillary venous malformations resistant to usual therapies including sirolimus, debulking surgical procedures or percutaneous sclerotherapies. We assessed the volume of vascular malformations using magnetic resonance imaging (MRI) for each patient. Alpelisib demonstrated improvement in all 25 patients. Vascular malformations previously considered intractable were reduced and clinical symptoms were attenuated. MRI showed a decrease of 33.4% and 27.8% in the median volume of PIK3CA and TEK malformations respectively, over 6 months on alpelisib. In conclusion, this study supports PI3Kα inhibition as a promising therapeutic strategy in patients with PIK3CA or TEK-related capillary venous malformations.

A Rare Case of Internal Jugular Venous Malformation Treated by Surgical Excision

This paper reports a case of an internal jugular venous malformation (IJVM) and route of treatment in a patient with limited symptoms. After history and imaging studies, a determination of surgical excision was made to rule out possible malignancy and future problems such as thrombosis. The mass was resected, and part of the IJVM was ligated. The mass had no identifiable malignancy, and the patient recovered fully with no complications. The paper highlights the importance of identifying venous malformations and highlights the reasoning behind the course of action.

Effect of catheter needle caliber on polidocanol foam stability in foam sclerotherapy

Background

Although sclerotherapy is widely used to treat vascular malformations (VMs), it is associated with several challenges. One significant issue is the insufficient understanding of the influence of various factors on the stability of polidocanol (POL) foam used in sclerotherapy.

Objective

This study aimed to explore the effect of the catheter needle caliber on foam stability when using POL with or without hyaluronic acid (HA) for the treatment of VMs.

Methods and materials

The Tessari method generated sclerosant foam using POL both with and without HA. We used catheters and syringe needles of various calibers, and the resulting foam was transferred into new syringes to facilitate a comparison of foam stability. Foam half-life (FHT) was utilized as a metric to assess foam stability.

Results

The study found that narrower needle calibers produced a more stable foam when POL was used alone; however, no significant effect was observed when HA was added. Furthermore, when the foam was expelled using catheters and syringe needles of the same size, no noticeable changes in the stability were observed.

Conclusion

When choosing needles of varying calibers, their effect on foam stability should be carefully considered, particularly when the foam contains HA.

The discriminative role of PROX-1 immunohistochemistry between venous malformation and lymphatic malformation of the deep type with no visible diagnostic surface skin lesion

BACKGROUND

Venous malformations (VMs) are distinguished from lymphatic malformations (LMs) when specific diagnostic skin lesions are present. In the deep type, this is difficult by clinico-radiologic evaluation alone. We aimed to investigate the usefulness of lymphatic vessel endothelial cell (LEC) markers for the differential diagnosis of the deep VMs and LMs.

METHODS

A retrospective study was conducted based on the medical records of patients with VMs and LMs who underwent biopsy with both D2-40 and PROX-1 immunohistochemistry. We compared the initial clinico-radiological diagnosis with the final pathological diagnosis and identified which ones showed a difference.

RESULTS

From 261 patients who had VMs and LMs, 111 remained after the exclusion of those who showed definite surface diagnostic features. After pathological diagnosis with the expressions of D2-40 and PROX-1, 38 of 111 (34.2%) patients' final diagnoses were changed. Among these 38 cases, diagnosis was not changed by D2-40 positivity alone, but changed by PROX-1 positivity alone (52.6%) or by both (47.4%). The diagnostic changes were more frequent in the deep category (43.7%) than in the superficial category.

CONCLUSIONS

Identifying the expression of D2-40, and especially PROX-1, in the differential diagnosis of VMs and LMs may provide important treatment guidelines and understanding their natural course.

Whole-lesion assessment of volume and signal changes after sclerotherapy of extremity venous malformations

PURPOSE

To investigate quantitative changes in MRI signal intensity (SI) and lesion volume that indicate treatment response and correlate these changes with clinical outcomes after percutaneous sclerotherapy (PS) of extremity venous malformations (VMs).

METHODS

VMs were segmented manually on pre- and post-treatment T2-weighted MRI using 3D Slicer to assess changes in lesion volume and SI. Clinical outcomes were scored on a 7-point Likert scale according to patient perception of symptom improvement; treatment response (success or failure) was determined accordingly.

RESULTS

Eighty-one patients with VMs underwent 125 PS sessions. Treatment success occurred in 77 patients (95 %). Mean (±SD) changes were -7.9 ± 24 cm3 in lesion volume and -123 ± 162 in SI (both, P <.001). Mean reduction in lesion volume was greater in the success group (-9.4 ± 24 cm3) than in the failure group (21 ± 20 cm3) (P =.006). Overall, lesion volume correlated with treatment response (ρ = -0.3, P =.004). On subgroup analysis, volume change correlated with clinical outcomes in children (ρ = -0.3, P =.03), in sodium tetradecyl sulfate-treated lesions (ρ = -0.5, P =.02), and in foot lesions (ρ = -0.6, P =.04). SI change correlated with clinical outcomes in VMs treated in 1 PS session (ρ = -0.3, P =.01) and in bleomycin-treated lesions (ρ = -0.4, P =.04).

CONCLUSIONS

Change in lesion volume is a reliable indicator of treatment response. Lesion volume and SI correlate with clinical outcomes in specific subgroups.

Ultrasound features of benign paediatric lumps: radiology-pathology correlation

Ultrasonography is an appropriate first-line imaging technique for the characterisation of paediatric lumps, given its relative accessibility and absence of radiation exposure. Together with a thorough history and examination, ultrasonography can help to distinguish benign lesions from malignancy. It can also aid further characterisation of benign lesions to inform onward investigation and management. This review features the evaluation of common benign paediatric lumps together with their characteristic sonographic features, following correlation with histopathology results or clinical follow-up.

Clinical Values of Whole-Body Blood Pool Scans and SPECT for Evaluation of Congenital Vascular Malformation

Purpose

This study examines the diagnostic potential of whole-body blood pool scintigraphy (WBBPS) using technetium-99 m-labeled red blood cells to detect congenital vascular malformations (CVMs). It aims to compare its efficacy with traditional imaging techniques such as magnetic resonance imaging (MRI) and ultrasonography (USG), emphasizing its potential advantages in terms of characterization of lesions and capacity for whole-body assessment.

Methods

The efficacy of WBBPS and single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging in diagnosing CVMs, comparing them with USG and MRI results, was evaluated in this retrospective study. Of the 38 patients, 21 were evaluated using these diagnostic methods, with CVMs classified according to the International Society for the Study of Vascular Anomalies guidelines. Also, this study aimed to elucidate the characteristics between WBBPS, SPECT/CT, USG, or MRI findings and their consistency with the final diagnosis.

Results

A total of 21 participants were included in this study, with an average age of 17.7 years old, with female predominance (57.1%). The most common diagnosis was vascular malformations (VMs) (71.4%), followed by combined vascular malformations (14.3%) and lymphatic malformations (9.5%). WBBPS demonstrated positive results in 95.2% of cases. Distinct imaging patterns for each condition were observed, with WBBPS being crucial in locating lesions.

Conclusion

The study findings suggested that WBBPS with SPECT/CT could be helpful in detecting occult VM lesions and ruling out a lymphatic malformation diagnosis. Thus, it can be employed in the evaluation of CVMs.

Venous malformation differential diagnosis with an odontogenic abscess on a pediatric patient. Case report and review of the literature

Venous malformations (VMs) are aberrant venous vessel angiogenesis present at birth. However, they can become apparent later in life, debuting in early childhood. This poses a clinical quest for surgeons, dentists, and pediatricians, as they might appear as a compressible mass in the head and neck region, not uncommonly mistaking them for odontogenic abscesses or other soft tissue tumors. The differential diagnosis can be challenging and imaging techniques are often needed. Ultrasounds are extremely useful initially as other diagnostic tools can be potentially harmful in the context of a VM. MRI is key as it provides accurate extension and location information, and allows to plan invasive treatment alternatives if the patient requires it. In this article, we present the case of a 6-year-old girl who was treated by mistake for an infection upon the diagnosis of an incipient odontogenic abscess instead of a venous malformation, and a literature review on VMs. Key words:Venous malformation, odontogenic abscess, differential diagnosis.

Comparison of bleomycin polidocanol foam vs electrochemotherapy combined with polidocanol foam for treatment of venous malformations

OBJECTIVE

This study aims to investigate the difference in safety and efficacy between two treatments for venous malformations (VMs), electrochemotherapy combined with polidocanol foam (ECP) and bleomycin polidocanol foam (BPF), providing alternative therapies for VMs.

METHODS

We conducted a retrospective review of 152 patients with VMs treated with ECP and BPF. Pre- and post-treatment magnetic resonance images (MRIs) were collected, and clinical follow-up assessments were performed. Imaging results were used to calculate lesion volume changes. Clinical outcomes included changes in pain and improvements in perceived swelling. Patients were followed up at 1 week and 6 months after surgery. All emerging complications were documented in detail.

RESULTS

Of the 152 patients, 87 (57.2%) received BPF treatment, and 65 (42.8%) received ECP treatment. The most common location of VMs was the lower extremities (92/152; 60.2%), and the most common symptom was pain (108/152; 71.1%). Forty-three patients had previously undergone therapy in the BPF group (43/87; 49.4%), whereas 30 patients had received prior treatment in the ECP group (30/65; 46.2%). The study found that the percentage of lesion volume reduction in the BPF group was not significantly different from that in the ECP group (75.00% ± 17.85% vs 74.69% ± 8.48%; P = .899). ECP was more effective when the initial lesion volume was greater than 30 mL (67.66% ± 12.34% vs 73.47% ± 8.00%; P = .048). Patients treated with BPF had significantly less posttreatment pain than those treated with ECP, in different baseline lesion size. In the overall sample, pain relief was significantly higher in the BPF group than in the ECP group (4.21 ± 1.19 vs 3.57 ± 0.76; P = .002). However, there was no difference in pain relief between the two groups for the treatment of initially large VMs (4.20 ± 0.94 vs 3.70 ± 0.87; P = .113). The ECP group was significantly more likely to develop hyperpigmentation (5/87; 5.75% vs 11/65; 16.92%; P = .026) and swelling (9/87; 10.34% vs 16/65; 24.62%; P = .019) 1 week after surgery than the BPF group.

CONCLUSIONS

Our study demonstrates that both BPF and ECP are effective treatments for VMs, with BPF being a safer option. ECP is a better choice for patients with the initial lesion volume greater than 30 mL, but it is more likely to lead to early swelling and hyperpigmentation.

Progress about the fibro-adipose vascular anomaly: A review

Fibro-adipose vascular anomaly (FAVA) is a rare and complex vascular malformation associated with persistent pain, limb contracture, and even restriction of activity. However, the pathophysiology of FAVA remains unclear. Although FAVA is a benign vascular malformation, it is highly misdiagnosed and often thus undergoing repeated surgical resection and interventional sclerotherapy, resulting in worsening of symptoms and irreversible dysfunction. Therefore, aggressive diagnosis and treatment are essential. There are several different treatment options for FAVA, including surgical resection, sclerotherapy, cryoablation, drug therapy, and physical therapy. This article reviews the clinical manifestations, pathological features, pathogenesis, and treatment methods of FAVA.

Retained foreign body misdiagnosed as a low flow vascular malformation: A case report

A 21-year-old woman presented with 1 year history of progressive dorsal right foot pain with no recollection of trauma. The physical exam did not reveal any unusual appearance to the plantar or dorsal skin surfaces. Specifically, no scars were seen. Foot radiographs were unremarkable. The presumed etiology after Doppler ultrasound (US) and MRI was a likely venous or venolymphatic malformation. She received 2 rounds of sclerotherapy 12 months apart with transient symptomatic clinical improvement. After the second sclerotherapy treatment, repeat MRI revealed dorsal extension of the lesion with skin involvement, prompting referral for surgical intervention. At surgery, a 3 cm wood splinter was found surrounded by granulation tissue. After showing the patient the resected splinter, she recalled stepping on a wooden broomstick that punctured the bottom of her foot in her childhood. She stated she also remembered pulling a splinter out of her foot. This case demonstrates the unusual and rare appearance of a chronic retained foreign body creating a cystic lesion in the foot presumed to be a low-flow vascular malformation on US and MRI.

CT and MRI Findings of Low-Flow Mediastinal Vascular Malformation: A Case Report

Mediastinal vascular malformations are rare and their diagnosis can be challenging. Imaging is vital for diagnosing mediastinal vascular malformations and can help avoid unnecessary invasive procedures. Herein, we report the detailed CT and MRI findings of a rare low-flow mediastinal vascular malformation in an asymptomatic 63-year-old male.

Percutaneous Sclerotherapy of Large Venous Malformations Using Consecutive Polidocanol and Bleomycin Foam: MR Imaging Volumetric and Quality-of-Life Assessment

PURPOSE

To retrospectively evaluate sclerotherapy using consecutive polidocanol and bleomycin foam (CPBF) for large untreated venous malformations (VMs) and/or those resistant to prior treatment.

MATERIALS AND METHODS

This retrospective study included all patients treated with CPBF for untreated VMs larger than 10 mL and/or refractory to treatment between May 2016 and October 2019. Baseline and follow-up VM volumes were measured on fat-suppressed T2-weighted magnetic resonance (MR) imaging. Outcome was evaluated on postprocedural MR imaging volumetry and by a retrospective survey assessing clinical response and adverse events. Imaging response was considered good for volume reduction from 50% to 70% and excellent for volume reduction ≥70%. Symptoms and quality-of-life (QoL) scores were compared before and after CPBF sclerotherapy.

RESULTS

Forty-five patients (mean age, 16 years; range, 1-63 years; 25 males) with 57 VMs were analyzed and treated by 80 sclerotherapy. Sixty percent (27 of 45) of patients had undergone prior treatment for VM. Median VM volume was 36.7 mL (interquartile range, 84 mL) on pretherapy MR imaging. Good and excellent results after the last sclerotherapy were achieved in 36% (16 of 45) and 29% (13 of 45) of patients, respectively, corresponding to a decrease of >50% in 60% (34 of 57) of VMs. QoL score increased by at least 3 points, regardless of initial symptoms. Most patients did not desire additional sclerotherapy owing to near complete symptomatic relief, even for patients who did not achieve a good response. Swelling, pain, and motor impairment scores significantly improved after CPBF. Adverse events included fever (44%, 15 of 34) and nausea/vomiting (29%, 10 of 34).

CONCLUSIONS

CPBF sclerotherapy represents an effective therapy for large and/or refractory VMs with minimal adverse events.

Clinical outcomes and predictors of bleomycin polidocanol foam sclerotherapy treatment response in venous malformations

OBJECTIVE

To evaluate the safety and efficacy of bleomycin polidocanol foam (BPF) sclerotherapy for venous malformations (VMs) and analyze the associated clinical outcomes and predictors.

METHODS

We retrospectively assessed BPF sclerotherapy outcomes in 138 patients with VMs. We analyzed pain levels, lesion volume reduction, and subjective perception of response. Logistic regression analysis was performed to identify potential predictors of treatment outcome. Additionally, we carefully monitored and recorded complications.

RESULTS

There was a notable average reduction in lesion volume by 78.50% ± 15.71%. The pain numerical rating scale (NRS) score decreased from 4.17 ± 2.63 prior to treatment to 1.05 ± 1.54 afterward, and 70.3% of the patients experienced effective relief after a single BPF treatment. Multivariate analysis revealed that a high baseline NRS (odds ratio [OR]:  4.026) and elevated activated partial thromboplastin time (APTT, OR: 1.200) were positive predictors of pain reduction. Additionally, a high baseline NRS score (OR: 1.992) and elevated thrombocytocrit (PCT, OR: 2.543) were positive predictors of incomplete postoperative pain relief. Minor complications occurred in 31 (22.46%) patients.

CONCLUSION

BPF sclerotherapy is safe and effective for VMs, resulting in significant reduction in lesion volume, improved symptoms, and minimal complications. APTT and PCT levels are important predictors of pain outcomes following BPF treatment.

Alpelisib for treatment of patients with PIK3CA-related overgrowth spectrum (PROS)

PURPOSE

PIK3CA-related overgrowth spectrum (PROS) encompasses several rare conditions resulting from activating variants in PIK3CA. Alpelisib, a PI3Kα-selective inhibitor, targets the underlying etiology of PROS, offering a novel therapeutic approach to current management strategies. This study evaluated the safety and efficacy of alpelisib in pediatric and adult patients with PROS.

METHODS

EPIK-P1 (NCT04285723) was a non-interventional, retrospective chart review of 57 patients with PROS (≥2 years) treated with alpelisib through compassionate use. Patients had severe/life-threatening PROS-related conditions and confirmed PIK3CA pathogenic variant. The primary end point assessed patient response to treatment at Week 24 (6 months).

RESULTS

Twenty-four weeks (6 months) after treatment initiation, 12 of 32 (37.5%) patients with complete case records included in the analysis of the primary end point experienced a ≥20% reduction in target lesion(s) volume. Additional clinical benefit independent from lesion volume reduction was observed across the full study population. Adverse events (AEs) and treatment-related AEs were experienced by 82.5% (47/57) and 38.6% (22/57) of patients, respectively; the most common treatment-related AEs were hyperglycemia (12.3%) and aphthous ulcer (10.5%). No deaths occurred.

CONCLUSION

EPIK-P1 provides real-world evidence of alpelisib effectiveness and safety in patients with PROS and confirms PI3Kα as a valid therapeutic target for PROS symptom management.

Sclerotherapy of Venous Malformations Using Polidocanol: Effectiveness, Safety, and Predictors of Outcomes and Adverse Events

PURPOSE

To assess the effectiveness, safety, and predictors of outcomes and adverse events for percutaneous sclerotherapy using polidocanol for the treatment of venous malformations (VMs).

METHODS

A retrospective single-center analysis was performed, including patients with VMs who were treated with sclerotherapy using polidocanol between January 2011 and November 2021 at a tertiary center. Demographic characteristics, clinical data, and radiologic features were analyzed, and the influence of patient- and VM-related factors on the subjective clinical outcome and adverse events were investigated using a multivariate logistic regression analysis.

RESULTS

In total, 167 patients who received 325 treatment sessions were included in this study. Overall symptom improvement was observed in 67.5%, stable symptoms were observed in 25.0%, and worsening was reported in 7.5% (clinical follow-up, 1.04 ± 1.67 years). The total adverse event rate was 10.2%, with an overall rate of 4.2% for permanent adverse events within the cohort. In multivariate analysis, the clinical outcome was worse in children (P = .01; 57.1% symptom improvement in children [age, <18 years] and 79.7% in adults), and adverse events were more frequently observed after the treatment of VMs located at the extremities (P < .01; 8.4% for VMs of the extremities and 1.2% for VMs in other locations).

CONCLUSIONS

Sclerotherapy using polidocanol can be an effective treatment option for VMs with an acceptable safety profile. However, it can be less effective in children, and adverse events can be more frequently expected for VMs of the extremities.

Study of vascular sclerosing agent based on the dual mechanism of vascular endothelial cell damage-plasmin system inhibition

Venous malformations are a vascular disorder. Currently, the use of chemical sclerosing agents is a common clinical approach for the treatment of venous malformations. However, the effectiveness of existing sclerosing agents is unsatisfactory and often accompanied by severe side effects. In this study, we have developed a novel cationic surfactant-based sclerosing agent (POL-TA) by conjugating the plasmin inhibitor tranexamic acid (TA) with a nonionic surfactant polidocanol (POL) through an ester bond. POL-TA induces endothelial cell damage, triggering the coagulation cascade and thrombus formation. Moreover, it releases TA in vivo, which inhibits plasmin activity and the activation of matrix metalloproteinase (MMPs), thereby stabilizing the fibrin network of the thrombus and promoting vascular fibrosis. We have established a cell model using venous malformation endothelial cells and assessed the cellular damage and underlying mechanisms of POL-TA. The inhibitory effects of POL-TA on the plasmin-MMPs system were evaluated using MMP-9 activity assay kit. Additionally, the mice tail vein model was employed to investigate the vascular sclerosing effects and mechanisms of POL-TA.

Sclerotherapy, cryoablation, and surgical fixation of an intraosseous tibial venous malformation

Intraosseous vascular malformations are rare vascular anomalies that present unique treatment challenges due to structural instability, embolization and sclerotherapy resistance, and tendency to recur. Patients may have clinical manifestations including pain, functional impairment, increased fracture risk, and decreased quality of life. Image-guided ablation techniques are emerging interventional treatment options for soft tissue tumors and complicated vascular anomalies. Percutaneous image-guided cryoablation offers a potential alternative as an isolated or adjunct therapy for intraosseous vascular malformations.

Impact of puberty on procedure frequency for treatment of simple head and neck lymphatic and venous malformations

OBJECTIVE

Puberty has been shown to accelerate growth of vascular malformations, including lymphatic (LM) and venous malformations (VM). This study aims to compare the number of procedures performed before and after puberty in patients with LM and VM to assess whether the onset of puberty results in higher treatment frequency.

METHODS

A retrospective review of head and neck LM and VM patients who were evaluated between January 2009 and December 2019 was performed. Patient demographics, lesion characteristics, and procedural details were recorded. For the purposes of this study, 11 years or older in females and 12 years or older in males were the established cut-offs for the onset of puberty.

RESULTS

After initial screening of 357 patients, 83 patients were included in the study based on inclusion criteria. There were 34 patients with LM (41 %) and 49 with VM (59 %). The mean age at diagnosis was 6.1 ± 10.9 years (LM: 4.2 ± 7.0, VM: 7.4 ± 12.9, p = 0.489). 68 patients underwent treatments, which included sclerotherapy, surgical excision, and/or laser. For all patients, the average number of lifetime treatments when initiated before puberty was 3.78 ± 2.81 and when initiated after puberty was 2.17 ± 1.37 (p = 0.022). Patients diagnosed pre-puberty were more likely to undergo treatments vs. those diagnosed after puberty (OR 10.00, 95 % CI: 2.61-38.28, p < 0.001).

CONCLUSION

We found that the number of treatments was fewer in those who started treatment after puberty. This finding suggests that providers may elect to proceed with observation in asymptomatic patients, given that waiting until after the onset of puberty has not shown an increase in the procedural load on patients.

Overview of peripheral arteriovenous malformations: From diagnosis to treatment methods

Based on the latest classification by the International Society for the Study of Vascular Anomalies in 2018, vascular malformations (VMs) can be categorized into simple, combined VMs of major named vessels, and VMs associated with other anomalies. Simple VMs include lymphatic, venous, capillary, and arteriovenous malformations (AVMs). AVMs represent disorders of direct arteriovenous shunts caused by the absence of a capillary bed between the involved arteries and veins. This abnormal vascular communication causes arterial blood to accumulate in the venous vessels, thus resulting in venous hypertension and characteristic clinical manifestations, such as pulsation, tremors, and elevated temperature. AVMs can occur sporadically or as manifestations of syndromic lesions and are considered among the most complex and challenging VMs. The diagnosis and treatment of AVMs can vary depending on the lesion location and associated clinical symptoms, thus complicating their management. Herein, we discuss peripheral AVMs in terms of their clinical manifestations, imaging examinations, and staging systems to provide a comprehensive reference for the treatment, evaluation methods, and follow-up procedures for this vascular anomaly.

Utilization of Healthcare Resources by Vascular Anomaly Patients: An Assessment of Healthcare Burden by Lesion Complexity

Background

Vascular anomalies (VAs) are heterogeneous lesions. Symptoms vary widely by lesion type and complexity. VA patients often require life-long interdisciplinary care; however, there is a paucity of data on the healthcare utilization of VA patients, and their burden on the healthcare system remains largely unquantified. We hypothesize that healthcare utilization by complex lymphatic malformation (LM) and venous malformation (VM) patients will be significantly higher compared with simple LM and VM patients.

Methods

A retrospective, longitudinal study was performed of LM/VM patients seen through multidisciplinary VA clinics between January 1, 2019 and December 31, 2020. Data were collected from each patient's first presentation through December 31, 2021 and included number of office visits, imaging studies, specialists involved, procedures, hospitalization data, and approximate costs, normalized to per year utilization. Patients were divided into "simple" and "complex" LMs/VMs. Involvement of the airway, more than one anatomic area, and/or complex lymphatic anomalies were defined as "complex."

Results

In total, 28 simple and 29 complex LM patients and 51 simple and 18 complex VM patients were identified. Complex LM and VM patients had significantly higher numbers of imaging studies, specialists involved, procedures and hospitalizations, and costs incurred. Complex LM patients also had significantly higher per year office visits.

Conclusions

VA care is chronic and costly, especially for complex LM/VM patients. LM/VM complexity was a predictor for increased inpatient and outpatient healthcare utilization and higher costs. Better awareness of the healthcare utilization trends of LM/VM patients will allow for improved counseling for these patients regarding prognosis and expectations.

Baseline Quality of Life in Pediatric Patients With Low-flow Vascular Malformations

OBJECTIVE

The aim of this study was to quantify and describe baseline patient and parent-proxy health-related quality of life scores in patients with low-flow vascular malformations at a single, tertiary-care vascular anomalies clinic.

STUDY DESIGN

This is a retrospective study of data collected on patients with low-flow vascular malformations between the ages of 2 to 25 who were seen at a single, tertiary-care center vascular anomalies clinic. A total of 266 patients are included in this study.

RESULTS

Patients with lymphatic malformations report decreased quality of life scores as compared with venous malformations in the emotional, psychological, school, and social domains. Patients with lower extremity malformation report decreased quality of life scores as compared with head/neck, trunk, upper extremity, and multifocal malformations; most notably in the physical domain.

CONCLUSIONS

Treatment of low-flow vascular malformations should aim to improve patient quality of life. The use of standardized health-related quality of life measures in this study quantifies baseline quality of life scores among patients with low-flow vascular malformations.

Value of fat-suppressed T2-weighted imaging for predicting short-term pain relief after sclerotherapy for venous malformations in the extremities

PURPOSE

This study aimed to evaluate the value of fat-suppressed T2-weighted imaging (FS-T2WI) for predicting short-term pain relief after polidocanol sclerotherapy for painful venous malformations (VMs) in the extremities.

MATERIALS AND METHODS

This retrospective study included patients with painful VMs in the extremities between October 2014 and September 2021, had their first sclerotherapy without history of surgical therapy, and underwent magnetic resonance imaging before sclerotherapy. Pain relief was assessed 2 months after 3% polidocanol sclerotherapy and was categorized as follows: progression, no change, partial relief, or free of pain. The associations between pain relief and imaging features on FS-T2WI were analyzed.

RESULTS

The study included 51 patients. The no change, partial relief, and free of pain groups included 6 (11.8%), 25 (49.0%), and 20 (39.2%) patients, respectively. No patient experienced progressive pain. The lesion diameter was ≤ 50 mm in 13 (65.0%) patients in the free of pain group, whereas it was > 50 mm in all patients in the no change group (p = 0.019). The lesions showed well-defined margin in 15 (75.0%) patients in the free of pain group, whereas they showed ill-defined margin in 5 (83.3%) patients in the no change group (p = 0.034). The most common morphological type was cavitary in the free of pain group (14 [70.0%] patients), whereas there was no patient with cavitary type lesion in the no change group (p = 0.003). Drainage vein was demonstrated in 6 (100%), 22 (88.0%), and 11 (55.0%) patients in the no change, partial relief, and free of pain group, respectively (p = 0.011).

CONCLUSION

A lesion size of 50 mm or less, a well-defined margin, a cavitary type, and no drainage vein on FS-T2WI were significant features for predicting short-term pain relief after polidocanol sclerotherapy for painful VMs in the extremities.