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Choi BC, Min BW, Lee KJ. Femoral Shaft Fracture in Klippel-Trenaunay-Weber Syndrome Patients - What to Do to Reduce Bleeding Risk: A Case Report. Hip Pelvis 2022; 34:262-268. [PMID: 36601615 PMCID: PMC9763826 DOI: 10.5371/hp.2022.34.4.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/22/2022] [Accepted: 08/09/2022] [Indexed: 12/14/2022] Open
Abstract
A fracture of the affected extremity in patients with Klippel-Trenaunay-Weber syndrome can be fatal due to massive bleeding and show poor results. A 42-year-old male presented with an old fracture of the right femoral shaft with metal failure. We planned an operation to remove the previously fixed plate and to perform re-fixation using an intra-medullary nail. Preoperative angiography was performed and the arteriovenous malformations were embolized in order to reduce the risk of bleeding. After angiography, the previously fixed plate was removed. After the operation, a second angiography was performed immediately and the venous malformation was embolized. One week after the first operation, a second operation was performed in order to reduce the fracture and to perform re-fixation using an intramedullary nail. The patient is being followed without major complication over a period of seven years after surgery. We recommend careful planning of preoperative and postoperative angiography and embolization in order to reduce the risk of bleeding in patients with Klippel-Trenaunay-Weber syndrome.
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Affiliation(s)
- Byung-Chan Choi
- Department of Orthopedic Surgery, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Byung-Woo Min
- Department of Orthopedic Surgery, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung-Jae Lee
- Department of Orthopedic Surgery, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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Zhimei CBS, Shuai ZP, Ping WBS, Hong ZBS, Zhijing WBS, Shi ZBS. Use of Ultrasound and Digital Subtraction Angiography for Arteriovenous Malformations in a Patient with Klippel-Trenaunay-Weber Syndrome. Advanced Ultrasound in Diagnosis and Therapy 2020. [DOI: 10.37015/audt.2020.200009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Ishikawa K, Yamamoto Y, Funayama E, Furukawa H, Sasaki S. Wound-Healing Problems Associated with Combined Vascular Malformations in Klippel-Trenaunay Syndrome. Adv Wound Care (New Rochelle) 2019; 8:246-255. [PMID: 31832274 DOI: 10.1089/wound.2018.0835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/18/2018] [Indexed: 01/19/2023] Open
Abstract
Significance: In Klippel-Trenaunay syndrome (KTS), management of a wound in the affected limb can be difficult because of the underlying vascular malformations present. This review describes the characteristics of KTS with wound complications in light of the genetic and molecular mechanisms of the disease. Recent Advances: KTS is a slow-flow combined vascular malformation characterized by the triad of capillary malformation, venous malformation with or without lymphatic malformation, and limb overgrowth. KTS is encompassed within the phosphatidylinositol-4,5-bisphosphate3-kinase catalytic subunit alpha (PIK3CA)-related overgrowth spectrum (PROS), having recently been linked to activating mutations in the PIK3CA gene. This clearly has implications for both molecular diagnosis and potential treatment strategies for the disease. Critical Issues: KTS should be distinguished from Parkes Weber syndrome, a fast-flow-type combined vascular malformation with limb overgrowth. Individualized management is needed for KTS and should be focused on the treatment of symptoms. Future Directions: Targeted therapies that inhibit the phosphoinositide 3-kinase signaling pathway are a potential treatment option for PROS.
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Affiliation(s)
- Kosuke Ishikawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Furukawa
- Department of Plastic and Reconstructive Surgery, Aichi Medical University, Nagakute, Japan
| | - Satoru Sasaki
- Department of Plastic and Reconstructive Surgery, Center for Vascular Anomalies, Tonan Hospital, Sapporo, Japan
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Azevedo Pereira da Silva M, Vaz de Melo MR, de Oliveira e Britto Villalobos MI, Assunção e Alves Cardoso C, Scigliano Valério C, Manzi FR. Klippel-Trenaunay-Weber Syndrome: A clinical case report. Pediatric Dental Journal 2018; 28:7-12. [DOI: 10.1016/j.pdj.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kazanasmaz H, Calik M. Coexistence of Chiari malformation type I and isolated hemihypertrophy in a 15-year old girl: a case report. J Clin Exp Invest 2017. [DOI: 10.5799/jcei.343203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Orszagh M, Schulte D, Korinthenberg R, Schumacher M. Analysis of Hemodynamics by MR-Angio and Embolization of Klippel-Trenaunay-Weber Syndrome: Five Year Follow-up. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/19714009990120s234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A newborn male child was admitted with hypoxemia, high output failure, hypertrophic right lower limb with a segmental pink naevus flammeus, lymphatic edema, subcutaneous varices and multiple arteriovenous fistulae (AVF) spinal and pelvine; findings of the Klippel-Trenaunay- / Parkes-Weber-Overlap Syndrom (KTW). Because of a threatening right heart insufficiency caused by the shuntvolume, the child was embolized as early as 5 months of age. In the course of 5 years, a total of 17 spinal and pelvic feeding arteries were occluded in 6 sessions using Histoacryl, Platincoils or Ethibloc. The low weight of the child's body (4.3 kg) and cardiac insufficiency (CI) limited the amount of contrast agent and fluid. To reduce the amount of contrast agent used for diagnostic purposes we analyzed the pathological hemodynamics by magnetic resonance angiography (MRA). Within 5 years normal bodily development took place with no sings of exponential growth of the affected leg. We understand the “newly formed” fistulae in the current angiography as a local hemodynamic activation of persistent primitive arteriovenous communication caused by mesodermal disturbances, the degree of which correlate with the prognosis.
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Udayakumaran S, Onyia CU. Beckwith-Wiedemann syndrome and Chiari I malformation--a case-based review of central nervous system involvement in hemihypertrophy syndromes. Childs Nerv Syst 2015; 31:637-41. [PMID: 25686896 DOI: 10.1007/s00381-015-2642-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Beckwith-Wiedemann syndrome (BWS) is an unusual complex of abnormalities that includes mainly omphalocele, macroglossia, gigantism, visceromegaly, and neonatal hypoglycemia. Type I Chiari malformation, on the other hand, is defined as ectopia of the cerebellar tonsils below the plane of the foramen magnum. Only one case of association of BWS with Chiari I malformation has been previously reported in the literature. DISCUSSION Several conditions involving congenital hemihypertrophy have been previously reported in association with Type I Chiari malformation. The pathophysiological mechanism for most of these associations is thought to be quite complex and still remains unclear. However, the presence of tonsillar herniation in BWS has been explained by Tubbs and Oakes in the only one existing case report of BWS with Type I Chiari malformation in the literature, to be due to associated hemihypertrophy of the skull base. We additionally suggest that cerebellar hypertrophy may also contribute to the tonsillar herniation and fourth ventricular outlet obstruction. ILLUSTRATIVE CASE We now report our recent experience on this association following a review of the literature on association of other hemihypertrophy syndromes with the central nervous system anomalies. CONCLUSION We believe that a common pathogenesis of Type I Chiari malformation occurs in conditions of hemihypertrophy including BWS, probably secondary to dysmorphology involving the posterior cranial fossa, and is not just an associated finding.
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Affiliation(s)
- Suhas Udayakumaran
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, 682 041, India,
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Abstract
CASE A fourteen-year old patient with Klippel-Trénaunay-Weber syndrome presented with an eleven-year history of pain and subjective weakness in the median nerve distribution of the hand. Electromyography studies demonstrated chronic denervation, and magnetic resonance imaging ruled out vascular malformations as a cause of extrinsic compression. Despite the chronic compression of the median nerve within the carpal tunnel and known complications associated with Klippel-Trénaunay-Weber syndrome, a surgical release was performed. CONCLUSION Postoperatively, the patient noted immediate pain relief. At the time of the three-year follow-up, the subjective strength and function of the hand were greatly improved compared with the preoperative status. Even with symptoms suggesting decade-long compression, carpal tunnel release can be a safe and beneficial treatment for patients with Klippel-Trénaunay-Weber syndrome.
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Affiliation(s)
- Evan Siegall
- Atlanta Medical Center, 303 Parkway Drive N.E., Atlanta, GA 30312
| | - Joshua Ratner
- Hand and Upper Extremity Center of Georgia, Suite 1020, 980 Johnson Ferry Road N.E., Atlanta, GA 30342.
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Wankhade V, Singh R, Sadhwani V, Kodate P, Disawal A. Angiokeratoma circumscriptum naeviforme with soft tissue hypertrophy and deep venous malformation: A variant of Klippel-Trenaunay syndrome? Indian Dermatol Online J 2015; 5:S109-12. [PMID: 25593797 PMCID: PMC4290170 DOI: 10.4103/2229-5178.146180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Klippel-Trenaunay syndrome (KTS) is a cutaneous capillary malformation on a limb in association with soft tissue swelling with or without bony hypertrophy and atypical varicosity. The capillary malformation associated with KTS is port wine stain. Angiokeratoma circumscriptum naeviforme (ACN) is a congenital variant of angiokeratoma commonly present on the lower limb as a hyperkeratotic plaque. ACN is rarely associated with KTS. We report a case of ACN with soft tissue hypertrophy and deep venous malformation (possibly a variant of Klippel-Trenaunay) in a 4-year-old male child.
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Affiliation(s)
- Vaishali Wankhade
- Department of Dermatology, Government Medical College and Hospital, Nagpur, Maharashtra, India
| | - Rajesh Singh
- Department of Dermatology, Government Medical College and Hospital, Nagpur, Maharashtra, India
| | - Venus Sadhwani
- Department of Dermatology, Government Medical College and Hospital, Nagpur, Maharashtra, India
| | - Purnima Kodate
- Department of Pathology, Government Medical College and Hospital, Nagpur, Maharashtra, India
| | - Amit Disawal
- Department of Radiology, Government Medical College and Hospital, Nagpur, Maharashtra, India
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Revencu N, Boon LM, Dompmartin A, Rieu P, Busch WL, Dubois J, Forzano F, van Hagen JM, Halbach S, Kuechler A, Lachmeijer AMA, Lähde J, Russell L, Simola KOJ, Mulliken JB, Vikkula M. Germline Mutations in RASA1 Are Not Found in Patients with Klippel-Trenaunay Syndrome or Capillary Malformation with Limb Overgrowth. Mol Syndromol 2013; 4:173-8. [PMID: 23801933 DOI: 10.1159/000349919] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 01/19/2023] Open
Abstract
The RASA1 gene encodes p120RASGAP, a multidomain cytoplasmic protein that acts as a negative regulator of the RAS signalling pathway. Heterozygous loss-of-function RASA1 mutations were identified in patients with Parkes Weber syndrome and multifocal capillary malformations. This syndrome is characterised by a capillary blush on an extremity, arteriovenous microfistulas, and bony and soft tissue hypertrophy. The aim of this study was to test RASA1 in 2 disorders characterised by asymmetric limb enlargement and vascular malformations, namely Klippel-Trenaunay syndrome and regional capillary malformation with overgrowth. We did not identify any clear pathogenic change in these patients. Thus, besides clinical and radiological criteria, RASA1 testing constitutes an additional tool to differentiate Parkes Weber syndrome of capillary malformation-arteriovenous malformation (CM-AVM) from overlapping disorders.
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Affiliation(s)
- N Revencu
- Laboratory of Human Molecular Genetics, de Duve Institute, Brussels, Belgium ; Center for Human Genetics, Brussels, Belgium
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Fakir E, Roberts T, Stephen L, Beighton P. Klippel-Trenaunay-Weber syndrome: orodental manifestations and management considerations. ACTA ACUST UNITED AC 2009; 107:754-8. [PMID: 19464652 DOI: 10.1016/j.tripleo.2009.01.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 12/22/2008] [Accepted: 01/15/2009] [Indexed: 10/20/2022]
Abstract
Klippel-Trenaunay-Weber syndrome is characterized by a triad of features, namely, vascular nevi, venous varicosities, and hyperplasia of hard and soft tissues in the affected area. Involvement of the orofacial region is uncommon, but nevertheless, a wide range of orofacial abnormalities may necessitate specialized dental and anesthesia management. We have documented the manifestations in 2 affected persons, outlined the nosology, reviewed the literature, and tabulated craniofacial anomalies and orodental complications. Special emphasis is given to the hematologic factors (bleeding tendencies) and vascular involvement (hemangiomata) which may significantly influence orodental management and anesthesia.
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Affiliation(s)
- Ebrahim Fakir
- Faculty of Dentistry, University of the Western Cape, Cape Town, South Africa
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Abstract
Klippel-Trenaunay syndrome (KTS) is a congenital malformation syndrome involving blood and lymph vessels and disturbed growth of bone and soft tissues. The clinical presentation can be extremely variable. An extensive literature search showed that various authors used many different diagnostic criteria. Uniform diagnostic criteria are an absolute prerequisite for successful molecular studies and for comparisons between various studies on almost any aspect of the disorder. Based on data from 3 unusually experienced colleagues and our experience, we propose restrictive diagnostic criteria, which still respect the extremely variable nature of KTS. Important aspects are that growth can be both increased and decreased, very small arteriovenous fistula can be present, and varicosities do not need to be present. Several hypotheses regarding cause and pathogenesis in KTS exist, but none explains all KTS characteristics completely. We propose yet another hypothesis which is at variance with the hypothesis of paradominant inheritance.
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Abstract
We report 3 patients with Proteus syndrome (PS) who died suddenly from pulmonary embolism (PE). The first patient was a male diagnosed with PS at 12 years who had varicose veins, portal vein thrombosis, right iliac vein occlusion and recurrent PE. At age 25 years, he was admitted to the hospital with a severe headache. Despite therapeutic doses of warfarin, investigations for an acute episode of breathlessness showed PE and he was unable to be resuscitated. The second case was a 9-year-old male with PS who collapsed at home and could not be revived. Autopsy revealed that the cause of death was a PE associated with thrombosis of the deep veins (DVT). The third patient was a 17-year-old female undergoing inpatient treatment for sinusitis when she unexpectedly arrested. She could not be revived and a full autopsy revealed a large PE with no identified DVT. We conclude that PE is a serious complication of PS and recommend vigilance concerning the signs and symptoms of thrombosis and PE in individuals with PS, including children. Aggressive evaluation and treatment should be considered urgently in patients with PS and signs or symptoms of DVT.
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Affiliation(s)
- A M Slavotinek
- Genetic Diseases Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892-4472, USA
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Affiliation(s)
- A D Murray
- Department of Radiology, Aberdeen Royal Hospitals Trust, UK
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Abstract
Most cases of KTW syndrome are sporadic. However, in a few, other family members have some clinical manifestations of the syndrome, and an autosomal dominant mode of inheritance has been suggested. In this paper we present a family with an affected child who has large skin hemangiomata, overgrowth of the right leg, and severe heart defects. Her mother has a large capillary hemangioma on the left side of back and has developed severe varicosities in both lower extremities. The maternal grandmother developed severe varicosities in her legs at a young age. The clinical signs found in the mother and maternal grandmother represent a milder phenotype and might be explained as variable expressivity of the syndrome. The family tree supports autosomal dominant inheritance.
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Affiliation(s)
- J M Ceballos-Quintal
- Centro de Investigaciones Regionales Dr. Hideyo Noguchi, Laboratorio de Genética, Universidad Autónoma de Yucatán, México
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Affiliation(s)
- P L Scheinman
- Department of Dermatology, Tufts University School of Medicine, Boston, Massachusetts, USA
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Abstract
Proteus syndrome is an overgrowth syndrome principally affecting cutaneous and skeletal tissues, accompanied by subcutaneous hamartomas. We report on a patient with predominantly skeletal and visceral involvement, including a cardiac mass and thickening of the myocardial septum affecting cardiac conduction and contraction.
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Affiliation(s)
- C Shaw
- Department of Neurology, Wellington Hospital, New Zealand
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