Value of the short time inversion recovery sequence of magnetic resonance imaging in the staging of Klippel-Trenaunay syndrome complicated with lymphedema

OBJECTIVE

Currently, the focus on limb lymphedema (LE) is on classification and staging. However, few scholars have conducted staging for Klippel-Trenaunay syndrome complicated LE (KTS-LE). This study aimed to investigate the value of the short time inversion recovery sequence of magnetic resonance imaging (MRI) in the staging of KTS-LE.

METHODS

Forty-six patients who were diagnosed with KTS-LE were recruited for this retrospective study from July 2011 to November 2022. Referring to the clinical staging standard of lower extremity LE of the International Society of Lymphology in 2020, all patients were divided into three groups: stages I, II, and III. The MRI indicators of the three groups were recorded and statistically compared: LE range (unilateral bilateral, lower limbs, only thighs, only calves and ankles), abnormal parts (skin thickening, abnormal subcutaneous fat signal, abnormal muscle signal, muscle hypertrophy or contraction, abnormal bone signal, hyperostosis), and subcutaneous soft tissue signs (parallel line sign, grid sign, band sign, honeycomb sign, lymph lake sign, crescent sign, and nebula sign).

RESULTS

There was a significant difference in the honeycomb sign among the three periods (P = .028). There was a significant difference between stage II and stage I disease (P < .05). There was a significant difference between stage II and stage III disease (P < .05). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the honeycomb sign in diagnosing KTS-LE of stage II were 87.5%, 63.2%, 33.3%, 96.0%, and 67.4%, respectively. In contrast, the other signs were not statistically significant among the three periods.

CONCLUSIONS

The short time inversion recovery sequence of MRI is of great value in KTS-LE. The honeycomb sign is an important imaging indicator for the diagnosis of stage II disease. It is necessary to evaluate the severity of edema with MRI for KTS-LE, which is very important for therapeutic options.

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

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

Subcutaneous Cavernous Haemangioma in a Patient with Klippel-Trenaunay Syndrome: A Case Report

Background

Klippel-Trenaunay syndrome (KTS) is a rare congenital disease that mainly involves blood vessels and is characterized by the presence of capillary malformations (port wine stains), varicose veins, soft tissue and/or bone hypertrophy.

Case Presentation

We report a 28-year-old man who was diagnosed 20 years ago with Klippel-Trenaunay syndrome. Approximately 3 years ago, he found enlarged masses on both upper extremities and a new dark red mass that was pathologically diagnosed as cavernous haemangioma appeared on the right index finger.

Conclusion

KTS is a rare and potentially multisystem disease requiring multidisciplinary management for which imaging examination is an important auxiliary diagnostic method. Various complications may occur during its development, so regular follow-up is required to prevent serious accidents.

Prenatal ultrasound diagnosis of Klippel-Trenaunay-Weber syndrome associated with umbilical cord hemangioma

We describe a case of prenatal diagnosed Klippel-Trenaunay-Weber syndrome, which mainly manifested as hypertrophy of the left thigh, and was associated with umbilical cord hemangioma and loss of heterozygosity (LOH) for 1q21.2 q44. This case report describes the second reported case associated with umbilical cord hemangioma and the first reported case with LOH for 1q21.2 q44.

Potential Utilization of Lymphoscintigraphy in Patients With Klippel-Trenaunay Syndrome

PURPOSE

Klippel-Trenaunay syndrome (KTS) is a rare disease that was characterized by vascular malformation. Lymphatic malformation was also commonly associated with KTS. However, the application of lymphoscintigraphy in the management of patients with KTS was rarely described. The purpose of this study is to assess whether the findings of lymphoscintigraphy can aid the management of the patients with KTS.

METHODS

A total of 28 patients with known KTS who underwent Tc-dextran lymphoscintigraphy with lower extremity tracer injection were included in this retrospective analysis. The images from lymphoscintigraphy were reviewed for any abnormalities in the body with the attention on the region of left subclavian-jugular venous angle.

RESULTS

In addition to abnormal activity in the other regions, abnormal activity in the left subclavian-jugular venous angle was visualized in over half of the patients (53.6%, 15/28). Based on the findings of the lymphoscintigraphy, 7 patients with left subclavian-jugular venous angle activity underwent thoracic duct decompression. In 4 patients with postsurgery follow-up, 3 achieved significant, measurable symptomatic relief.

CONCLUSIONS

Lymphoscintigraphy can be used to assess potential candidates for thoracic duct decompression to alleviate the symptoms in patients with KTS.

[Klippel-Trenaunay-Weber syndrome with vesical and uterine involvement treated by endoscopic and endovascular routes]

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

Multimodality imaging approach in a patient with Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder presenting with asymmetric limb hypertrophy, cutaneous capillary malformations and lower extremity varicosities. We discuss a 27-year-old man born with varicosities on both lower extremities, which progressively enlarged. Physical examination showed a grossly enlarged right hand. There were multiple compressible varicosities, diffuse port-wine stains on the right leg and limb-length discrepancy on the left leg. CT angiogram and Doppler ultrasound revealed several venous varicosities. Ectatic veins in the right leg converge into the lateral marginal vein of Servelle, an embryonic vein, typically seen in KTS patients. KTS is diagnosed clinically and imaging plays a role in differentiating this from other disease entities that present similarly. Doppler ultrasound is the initial imaging of choice to characterise varicosities and to identify thrombosis and reflux. Plain radiographs confirm limb hypertrophy. MRI and CT angiograms are useful to evaluate vascular anomalies and its accompanying soft tissue changes.

Klippel-Trenaunay-Weber Syndrome with Atypical Presentation of Cerebral Cavernous Angioma: A Case Report and Literature Review

BACKGROUND

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare syndrome characterized by the triad of cutaneous hemangiomas, venous varicosities, and osseous-soft tissue hypertrophy of the affected limb. Clinical manifestations, genetic testing, and radiologic imaging are the key steps in diagnosing this syndrome.

CASE DESCRIPTION

An 18-month-old boy was brought for follow-up brain magnetic resonance imaging (MRI) with a history of right lower limb hypertrophy, cutaneous varicosities, and hemangiomas diagnosed at birth. A baseline MRI at 12 months revealed multiple hemorrhagic lesions within the cerebrum, the largest in the right temporal lobe, which was treated surgically at the age of 18 months because of its rapid growth. This is the youngest patient with KTWS treated surgically for intracranial hemangiomas.

CONCLUSION

KTWS is a rare disease with a wide range of manifestations. Multisystemic evaluation of this group of patients should be performed to identify cavernous hemangiomas at the early stage of life and adequately treat them in the future. Treatment of KTWS patients with cavernous hemangiomas should not be different from the treatment of patients with any other hemangiomas, and surgical intervention should be considered on a case-to-case bases.

Isolated bilateral external iliac vein aplasia

We present a case of 11-year-old girl with a history of prominent superficial veins over abdomen and thorax since birth. A superficial vein extending from either inguinal region joined in umbilical region and extended up to right supraclavicular region. Other features of Klippel-Trenaunay syndrome like nevus, limb edema were absent. On radiological investigations both external iliac veins could not be visualized and venous return from lower limbs was draining into the right subclavian vein via these superficial veins. Both external iliac veins could not be identified during surgery.

Thrombus in transit within a patent foramen ovale: an argument for consideration of prophylactic closure?

Recurrent pulmonary embolism (PE) in prothrombotic patients with patent foramen ovale (PFO) is not considered a setting for elective PFO closure. We describe a 35-year-old woman with known PFO, recurrent PE on warfarin, and Klippel-Trenaunay syndrome-a condition with predisposition for thromboembolism-who suffered concurrent saddle PE and devastating stroke with further impending paradoxical embolus across the PFO. Optimal management in patients with biatrial thromboembolus caught in transit across PFO is challenging. Patients with recurrent PE, prothrombotic states, and PFO should be considered for PFO closure. Prompt diagnosis of impending paradoxical embolus with echocardiography and consideration of surgical removal and PFO closure are critical.

Abnormal Tc99m sulesomab in Klippel-Trenaunay syndrome

Tc-99m sulesomab is indicated in bone and joint infection, but reading of scans can be affected by pre-existing conditions. This case report describes a case of Klippel-Trenaunay syndrome (KTS) which results in vascular malformations of one or more limbs. Tc-99m sulesomab imaging demonstrated persistent blood pool activity up to 20 hours post injection. However, despite this, septic arthritis could be identified with confidence in the same limb.

Sonographic identification of lower limb venous hypoplasia in the prenatal diagnosis of Klippel-Trénaunay syndrome

We report the prenatal identification of lower-limb venous hypoplasia to support a provisional prenatal diagnosis of Klippel-Trénaunay syndrome (KTS). Ultrasound assessment of a fetus with marked lower-limb edema, cystic areas in the abdomen/pelvis/lower limbs and abnormal development of the feet demonstrated bilateral hypoplasia of the femoral and popliteal veins. The external iliac veins and the great saphenous veins were seen to be normal. The lower limb arterial system was present. These findings supported KTS as the most likely provisional diagnosis, and postnatal clinical evaluation confirmed that the infant is best classified in the spectrum of KTS. Venous hypoplasia was confirmed with a postnatal ultrasound examination of the lower limbs. This case suggests that careful examination of the lower-limb venous system may be helpful in making the prenatal diagnosis of KTS.

Gigantism of the lower limb in Klippel-Trenaunay syndrome: anatomy of the lateral marginal vein

The Klippel-Trenaunay syndrome is a combination of venous and capillary malformations associated with soft tissue and/or bony limb hypertrophy, with or without lymphatic malformations. Although persistent foetal veins are rare, the persistence of the lateral marginal vein is a common association in this syndrome. It results in venous hypertension, which gives rise to venous varicosities, which are commonly seen in this syndrome. This is a case report of a 28-year-old man with Klippel-Trenaunay syndrome, with persistence of the lateral marginal vein, affecting his right lower limb. He was treated with an above-knee amputation. The amputated limb was dissected to demonstrate the anatomy of the lateral marginal vein. To the best of the authors' knowledge, the gross anatomy of the lateral marginal vein has not been previously reported.

Overlapping of Sturge Weber syndrome and Klippel Trenaunay Weber syndrome

Sturge-Weber Syndrome (SWS) occurs sporadically with a frequency of approximately 1 in 50,000. SWS is a mesodermal phakomatosis. Klippel-Trenaunay Weber syndrome (KTWS) is another very rare phakomatosis. Overlap between SWS & KTWS is very rarely encountered. We report a 19 months old boy with features of both SWS and KTWS. The reported case had seizures, port wine haemangioma of the right side of the body, glaucoma of both eyes, subcortical calcification which were consistent with the Sturge Weber Syndrome; on the other hand he had also hypertrophy of the right side of the including the face and limbs, angiomatous skin naevus, varicosities consistent with the KTWS.

Das Klippel-Trenaunay Syndrom bei gleichzeitigem Vorliegen von Viszeralarterienaneurysmen

Das Klippel-Trenaunay Syndrom (KTS) ist eine kongenitale Angiodysplasie der venösen Gefäßstrombahn mit der Symptomtrias kutane vaskuläre Naevi, Hypertrophie einer Extremität sowie Varikose und venöse Malformation. Die Koinzidenz eines KTS mit arteriellen Malformationen im Sinne von Nierenarterienaneurysmen findet sich in der Literatur lediglich in zwei Beschreibungen. Wir berichten über einen 40-jährigen Patienten, bei dem, neben einem KTS Aneurysmen einer A. renalis, der A. lienalis, der A. mesenterica superior sowie einer A. und V. poplitea beobachtet wurden. Neben der Darstellung des diagnostischen und therapeutischen Verlaufs wird über die in der Literatur dargestellten klinischen Erfahrungen berichtet. Differentialdiagnostisch sind zwei weitere Syndrome, ebenfalls aus dem Formenkreis der Phakomatosen, abzugrenzen: das Servelle-Martorell-Syndrom und das Frederick Parkes Weber-Syndrom.

Spinal arteriovenous malformations associated with Klippel-Trenaunay-Weber syndrome: a literature search and report of two cases

SUMMARY

Patients with Klippel-Trenaunay-Weber syndrome present with venous varices, cutaneous capillary malformations, and tissue hypertrophy, usually involving an extremity. A small but important subset also harbors arteriovenous malformations (AVMs) of the spine. We report 2 such cases, 1 with 3 concurrent spinal arteriovenous fistulas. These cases and our review of the literature emphasize the importance of screening the spine for AVMs. In addition, it is also important to investigate for the presence of multiple spinal AVMs.

Ultrasound-guided foam sclerotherapy in patients with Klippel-Trenaunay syndrome

BACKGROUND

Klippel-Trenaunay syndrome, a congenital disorder, is characterized by capillary malformation, varicosities and bony or soft tissue hypertrophy. Since there is no cure for this disorder, treatment is directed towards secondary prevention of venous hypertension and preservation of functional integrity of the legs. Elastic stockings are the mainstay of treatment and are indicated in all cases. Surgery is reserved only for a few selected symptomatic patients, however the outcome is unsatisfactory in most cases, with recurrent pain, edema, poor cosmetic result and limb deformity. Ultrasound-guided foam sclerotherapy is a recently introduced minimally invasive ambulatory procedure for the treatment of chronic venous insufficiency. It was recently introduced to treat this disorder.

OBJECTIVES

To evaluate the efficacy of USFS in the treatment of patients with Klippel-Trenaunay syndrome.

METHODS

Seven patients diagnosed with Klippel-Trenaunay, with massive lower extremity involvement, were treated with USFS between October 2003 and October 2005. Sclerovein (polidocanol, Resinag, Switzerland) 2-4% was used as the sclerosant. The signs, symptoms and overall patient satisfaction were assessed before, during and after the treatment.

RESULTS

Patients' mean age was 26 years (range 15-54). The CEAP clinical classification, with ascending severity ranging from 0 (no signs) to 6 (active venous ulcer), was C4 in five patients (71.5%) and C5 and C6 in one patient each. The average number of sessions was 14.5 (range 9-21). No major complications were encountered. All seven patients reported improvement in signs and symptoms. Five of the 7 patients (71%) were very satisfied with the cosmetic result.

CONCLUSION

USFS is an effective minimally invasive ambulatory technique, essentially pain-free and with excellent short-term results in patients with Klippel-Trenaunay syndrome (when the deep system is functional). Long-term results and larger study groups are warranted.

Klippel-Trenaunay syndrome: an unusual cause of pulmonary embolism

A 36-year-old female patient was admitted to the emergency department of our hospital with symptoms and signs of pulmonary embolism. Further evaluation established the diagnosis and anticoagulant therapy was immediately started. Physical examination revealed left lower extremity edema, prominent varicose veins, greater length of the involved limb and a capillary malformation extending from the lower abdomen down to the left knee. The diagnosis of Klippel-Trenaunay syndrome (KTS) was suspected and a color duplex scan was next performed revealing derangements in the lower extremity venous system including deep venous thrombosis. KTS is a congenital anomaly characterized by capillary malformation, extensive varicosities and limb hypertrophy. Anomalies of the deep and perforator venous system coexist and predispose to thromboembolic events. Pulmonary embolism is infrequently encountered in the setting of this syndrome.

[Klippel-Trenaunay syndrome and bone scintigraphy. A case report]

A 34-year-old man with Klippel-Trenaunay syndrome (KTS) was performed three bone scintigraphies. The first one to evaluate the possibility of avascular necrosis of the femoral head. Secondly, to dismiss a reflex sympathetic dystrophy in the affected lower limb and finally, due to knee pain. Magnetic resonance of pelvis and knee and biopsy of iliac spine were performed too.

Klippel-Trenaunay-Weber syndrome involving fetal thigh: prenatal presentations and outcomes

OBJECTIVES

We analyzed the prenatal presentations and perinatal outcomes of Klippel-Trenaunay-Weber syndrome involving fetal thigh in order to provide relevant information for prenatal counseling.

METHODS

We reviewed our own cases and searched for cases from Medline that met the criteria of Klippel-Trenaunay-Weber syndrome involving fetal thigh. Those with isolated hemangioma, hemangioendothelioma, and hemangiolymphangioma were excluded.

RESULTS

The cases of Klippel-Trenaunay-Weber syndrome involving fetal thigh, totaling 21, were collected for analysis. These included 19 cases from Medline search and two cases from our institution. The cases with lesions involving right thigh, left thigh, and both thighs were 12:8:1. The gender of affected fetuses was 9 male, 9 female, and 3 unknown. Among the 21 cases, 6 fetuses (28.57%, 6/21) had isolated thigh lesions, and the other 15 cases (71.43%, 15/21) had extensive lesions involving pelvis, abdomen, retroperitoneum, or thorax. Prenatal presentations varied with hypoechoic cystic mass with limb asymmetry, 95.23% (20/21); polyhydramnios, 38.09% (8/21); cardiomegaly, 19.04% (4/21); thick placenta, 9.52% (2/21); nonimmune hydrops fetalis, 9.52% (2/21); and oligohydramnios, 4.76% (1/21). Ten cases (47.62%, 10/21) underwent termination of pregnancy. For those who continued with pregnancy, the rate of complications with Kasabach-Merritt syndrome was 36.36% (4/11) and the mortality rate in the neonatal period was 45.45% (5/11). The causes of neonatal mortality in these five cases included consumption coagulopathy (Kasabach-Merritt syndrome), cardiac failure, sepsis, and prematurity.

CONCLUSIONS

Klippel-Trenaunay-Weber syndrome involving fetal thigh is rare. Our review showed that the location of involvement on the right thigh is more than on the left. Males and females were equally affected. Nearly three fourths of the cases had extensive involvement over other parts of the body. Prenatal ultrasound finding of a raised thigh mass of significant size and limb asymmetry were the most important features. The mortality rate was as high as 45.45% in the neonatal period.

Neuroradiologic findings in a young patient with characteristics of Sturge-Weber syndrome and Klippel-Trenaunay syndrome

The patient presented here has extensive hemangiomata plana, especially on the right forehead, right upper eyelid, and right leg, as well as right leg hypertrophy and macrocephaly. Cerebral magnetic resonance imaging (MRI) showed abnormalities in only one occipital lobe consisting of focal cortical atrophy, leptomeningeal enhancement, and ipsilateral choroid plexus enlargement. Mental and motor development is normal, and he has no seizures. The parents are consanguineous. Leg hypertrophy associated with ipsilateral cutaneous vascular malformations is suggestive of Klippel-Trenaunay syndrome. The patient's central nervous system abnormalities on MRI and the hemangiomata plana on the ipsilateral upper eyelid and forehead point to Sturge-Weber syndrome. We conclude that the patient has an overlap syndrome between Klippel-Trenaunay syndrome and Sturge-Weber syndrome.

Prenatal sonographic diagnosis of Klippel-Trenaunay-Weber syndrome: a case report

BACKGROUND

Klippel-Trenaunay-Weber syndrome is a rare congenital soft tissue anomaly with sporadic occurrence characterized by the triad of multiple hemangiomas, arteriovenous fistulas and unilateral limb hypertrophy.

CASE

A 27-year-old, pregnant woman was referred at 31 2/7 gestational weeks. On prenatal sonography, multiloculated cystic areas involving the left side of the thorax and hypertrophy of the upper portion of the left arm were diagnosed without diagnostic findings on color flow Doppler studies of the cutaneous hemangioma. There was no progression within the remainder of the gestational period, and the neonatal outcome was good.

CONCLUSION

Klippel-Trenaunay-Weber syndrome should be considered in the differential diagnosis of a fetal thoracic mass even if color flow Doppler studies of the mass are negative.

Diffuse hemangioma of the rectum detected on multi-slice CT in an 18-year-old woman with Klippel-Trenaunay syndrome

The paper reports a rare case of an 18-year-old woman with Klippel-Trenaunay syndrome, whose multi-phase multi-slice CT revealed diffuse colorectal hemangioma. The patient presented symptoms of consumption coagulopathy (Kasabach-Meritt syndrome) and intense collateral circulation in the course of portal hypertension. The CT lesions and possibilities of multiformat and 3D volume rendering reconstructions are presented. To our knowledge, this is the first report of diffuse hemangioma of the colon and rectum in a patient with KTS detected with multi-slice CT.

[Intravascular administration of pingyangmycin lipiodol emulsion for Klippel-Trenaunay syndrome: clinical analysis of 7 cases]

OBJECTIVE

To define the arteriographic features of Klippel-Trenaunay sydrome (KTS) and explore the feasibility of the treatment with intravascular administration of pingyangmycin lipiodol emulsion (PLE).

METHODS

Seven patients with KTS underwent arteriography followed by therapy with PLE administration (containing pingyangmycin 8-16 mg and lipiodol 4-6 ml) into the trunk of the arteries of all impaired extremities. The therapeutic effect and postoperative complications were observed.

RESULTS

Arteriography revealed abundant small branches of the runoff arteries, showing sinusoid changes of varied sizes in 5 cases by staining of the soft tissue. During the 3 to 30-month follow-up, swelling of the extremities was obviously improved in 5 cases after PLE therapy, which failed to produce obvious effect in 1 case and recurrence was detected in another. The major complications included paresthesia of the limbs, serum transaminase disorder and local skin necrosis.

CONCLUSION

Arteriography can detect the lesions of the arteries and soft tissues in the affected extremity of patients with KTS, intravascular administration of PLE was effective to alleviate the hypertrophy of the limbs.

Prenatal sonographic diagnosis of Klippel-Trenaunay-Weber syndrome associated with umbilical cord hemangioma

Klippel-Trenaunay-Weber syndrome (KTW), also known as angio-osteohypertrophy syndrome, is a complex developmental disorder characterized by asymmetric hemi-hypertrophy of limbs and trunk due to bony and soft tissue overgrowth that may extend across the midline, varicose veins, and cutaneous hemangiomata. This rare syndrome has been previously described in the prenatal period by ultrasonography, and in literature, there are quite different presentation of cases. We describe a case suggested as a KTW syndrome by prenatal ultrasonography. The sonographic appearance of an unilateral leg hypertrophy associated with irregular echolucent cystic areas was consistent with KTW syndrome. A spheric, weak-echogenic mass without any active blood flow located in the umbilical cord revealed by color Doppler ultrasonography was an unexpected finding. The postpartum examination confirmed the prenatal diagnosis.

Prenatal diagnosis of vascular anomalies

BACKGROUND/PURPOSE

Vascular anomalies are diagnosed prenatally with increasing frequency. The authors reviewed a group of children treated at their center who had an abnormal prenatal diagnosis to determine (1) fetal age at which the vascular anomaly was detected, (2) general diagnostic accuracy, and (3) impact on ante- and postnatal care. Their findings are compared with reported cases and series. The authors clarify appropriate terminology and underscore the need for interdisciplinary participation of specialists in the field of vascular anomalies.

METHODS

Patients referred during prenatal life and children with a history of abnormal antenatal findings seen at our vascular anomalies center during a 1-year period (September 1999 through August 2000) were included in this study. The fetal age at diagnosis, pre- and postnatal diagnoses, antenatal course, and neonatal outcome were obtained from the parents, through chart reviews, and through telephone interviews with the treating obstetricians.

RESULTS

Twenty-nine patients with vascular anomalies were identified: 17 had a correct prenatal diagnosis, and 12 had an incorrect diagnosis, an overall diagnostic accuracy of 59%. Capillary-lymphatic-venous malformations (CLVM) most often were correctly diagnosed (67%), followed by lymphatic malformation (LM, 62%) and hemangioma (59%). In the infants who received correct diagnoses in utero, there were no fetal deaths and there was no neonatal morbidity. Maternal steroids were administered for a fetus with an intrahepatic hemangioma and deteriorating cardiac function, with subsequent stabilization and successful delivery of a healthy neonate. Among infants with incorrect diagnoses, there was 1 postnatal death, 1 case of erroneous gender assignment, 1 case of unnecessary fetal surgical intervention, 1 unnecessary neonatal laparotomy, and 1 delay in diagnosis of a malignancy. Cesarean section was done for 65% of correctly diagnosed cases, (including 2 ex utero intrapartum [Exit] procedures) and for 33% of incorrectly diagnosed cases. Most diagnoses were made during the mid- to late second trimester and third trimester; only 4 cases (14%) were detected before 20 weeks.

CONCLUSIONS

In this series, accurate diagnosis optimized antenatal care by providing an opportunity for planning deliveries, for pharmacologic fetal intervention in 1 case, and for appropriate parental counselling. Inaccurate diagnosis was associated with significantly increased morbidity and mortality. Finally, the intrauterine diagnosis of LM should be distinguished from posterior nuchal translucency, an obstetric term applied to fetal lymphatic abnormalities detected in the first and second trimesters that do not manifest as postnatal LM.

Prenatal sonographic diagnosis of Klippel-Trénaunay-Weber syndrome with cardiac failure

This report describes the prenatal sonographic diagnosis of a case of Klippel-Trénaunay-Weber syndrome. The sonographic appearance of this disorder was characterized by the presence of multiple distorted cystic areas involving the right leg and abdomen and cardiomegaly with early fetal heart failure. Despite the prenatal detection of the extensive cutaneous and visceral involvement, the infant died soon after birth of high-output cardiac failure and Kasabach-Merritt syndrome.

Klippel-Trenaunay-Weber (KTW) syndrome: the use of in utero magnetic resonance imaging (MRI) in a prospective diagnosis

The diagnosis of the Klippel-Trenaunay-Weber (KTW) syndrome is rarely made antenatally. We report the use of both ultrasound and in utero magnetic resonance imaging (MRI) in the prenatal diagnosis of this syndrome. This is the first report of the use of prenatal MRI in the diagnosis of this condition. There was concordance in the findings of both modalities, with limb hypertrophy, and multiple haemangiomata - both subcutaneous and internally - demonstrated with ultrasound and MRI. The patient elected to terminate the pregnancy because of associated oligohydramnios and a small fetal chest noted at 20 weeks. The postmortem examination confirmed the antenatal diagnosis.

Surgical treatment of venous malformations in Klippel-Trénaunay syndrome

PURPOSE

Klippel-Trénaunay syndrome (KTS) is a complex congenital anomaly, characterized by varicosities and venous malformations (VMs) of one or more limbs, port-wine stains, and soft tissue and bone hypertrophy. Venous drainage is frequently abnormal because of embryonic veins, agenesis, hypoplasia, valvular incompetence, or aneurysms of deep veins. We previously reported on the surgical management of KTS. In this article, we update our experience.

METHODS

Twenty patients with KTS underwent surgical treatment for VMs between July 1, 1987, and January 1, 2000. This group represented 6.9% of 290 patients with KTS who were seen at our institution during this 12.5-year study period. Surgical indications, venous anatomy (determined with duplex scan, contrast phlebography, magnetic resonance imaging or magnetic resonance phlebography), operative procedures, and complications were reviewed, and outcomes were recorded.

RESULTS

Twelve male and eight female patients (mean age, 23.4 years; range, 7.7-40.6 years) underwent 30 vascular surgical procedures in 21 lower limbs. All 20 patients (100%) had varicose veins or VMs, 13 (65%) had port-wine stains, and 18 (90%) had limb hypertrophy. Pain was the most common complaint, which was present in 16 patients (80%), followed by swelling in 15 (75%), bleeding in 8 (40%), and superficial thrombophlebitis and cellulitis in 3 (15%). Imaging confirmed patent deep veins in 18 patients, hypoplastic femoral vein in 1, and entrapped popliteal veins bilaterally in 1. Four patients (20%) had large persistent sciatic veins (PSVs). The CEAP clinical classification was C-3 for 17 patients (85%), C-4 for 1 patient (5%), and C-6 for 2 patients (10%). Stripping of large lateral veins, avulsion, and excision of varicosities or VMs were performed on all limbs. Three patients required staged resections. The release of entrapped popliteal veins was performed in both limbs of one patient; another underwent a popliteal-saphenous bypass graft. One patient underwent excision of a PSV. Open and endoscopic perforator vein ligation was performed in one patient each. Two patients (12%) had hematomas that required evacuation. No patients had caval filter placement; none had postoperative deep venous thrombosis or pulmonary embolus. The mean follow-up was 63.6 months (range, 0-138 months). All patients reported initial improvement, but some varicosities recurred in 10 patients (50%), an ulcer did not heal in one, and a new ulcer developed in one, 8 years after surgery. Three patients underwent reoperation for recurrent varicosities. Follow-up CEAP scores were C-2 in 10 patients (50%), C-3 in 6 patients (30%), C-4 and C-5 in 1 patient each (5%), and C-6 in 2 patients (10%). Clinical scores improved from 4.3 +/- 2.2 to 3.1 +/- 2.3. (P =.03).

CONCLUSIONS

The management of patients with KTS continues to be primarily nonoperative, but those patients with patent deep veins can be considered for excision of symptomatic varicose veins and VMs. Although the recurrence rate is high, clinical improvement is significant, and reoperations can be performed if needed. Occasionally, deep vein reconstruction, excision of PSVs, or subfascial endoscopic perforator surgery is indicated. Because KTS is rare, patients should receive multidisciplinary care in qualified vascular centers.

Klippel-Trenaunay-Weber syndrome presenting as massive lymphangiohemangioma of the thigh: prenatal diagnosis

We report a case of Klippel-Trenaunay-Weber syndrome presenting prenatally as a massive congenital lymphangiohemangioma of the thigh. Routine ultrasonographic examination revealed multiple distorted cystic areas extending from the right flank through the right lower extremity of a 30-week fetus. A diagnosis of cystic lymphangioma of the thigh was suspected prenatally. Neonatal evaluation confirmed the prenatal findings. Neonatal color Doppler imaging revealed blood vessels within the tumor. The differential diagnosis is discussed together with available therapeutic procedures.

[Klippel-Trénaunay syndrome with involvement of the rectum. Surgical therapy after interventional-radiologic preparation]

Abdominal organs such as the rectum and urinary bladder are rarely involved in Klippel-Trénaunay syndrome, but may occasionally be the source of severe blood loss. Since frequently no isolated source of bleeding is identified, severe blood loss can result in a critical condition. This article describes an unusual multimodal treatment concept for a patient with Klippel-Trénaunay syndrome associated with severe recurrent rectal bleeding. We present the case of a 39-year-old patient with Klippel-Trénaunay syndrome and a history of rectal bleeding since childhood requiring multiple blood transfusions over the years. He was referred to our department in a state of continuous rectal bleeding. Preoperative work-up revealed a complete alteration of the rectum and the distal parts of the sigmoid/colon by hemangiomas, with diffuse bleeding from the destroyed rectal mucosa. Preoperatively the superior rectal artery was embolized. After a 48-h interval, sphincter-preserving complete rectal excision including the sigmoid/colon was performed followed by a colon pouch anal anastomosis and protective loop ileostomy.

Prenatal sonographic appearances of Klippel-Trenaunay-Weber syndrome

A case of prenatal Klippel Trenaunay-Weber syndrome is presented, with a description of the sonographically observed disease progression in utero. The appearance of a complex thoracic multicystic mass in association with progressive unilateral lower limb enlargement was strongly suspicious of this disorder. Colour-flow Doppler studies of the cutaneous haemangiomata in utero were not of diagnostic assistance in this case. The prenatal detection of the large cutaneous haemangiomata was of critical importance in minimizing delivery trauma for the mother and fetus.

Klippel-Trenaunay syndrome

Patients with Klippel-Trenaunay (KT) syndrome have a complex constellation of anomalies that includes cutaneous capillary malformation (usually on an affected limb), abnormal development of the deep and superficial veins, and limb asymmetry, usually enlargement. Mixed vascular malformations may be present and include capillary, venous, arterial, and lymphatic systems. The records of 79 patients referred for vascular anomalies were reviewed and 49 were found to have the three "cardinal" anomalies of KT syndrome. Twenty-six females and 23 males had 46 affected legs (27 right legs), 23 affected arms (15 right), 21 affected trunks, and 10 affected heads. Thirty-six had only one affected quadrant, 8 had two, and 5 had three or more. Although 40 patients had increased limb girth, measurable length discrepancy was noted in only 17 individuals. Patients were evaluated using a noninvasive imaging strategy including color duplex ultrasonography, MRI, lymphoscintigraphy, and plain radiographs. Treatment included compression, pulsed-dye laser treatment, reduction of arteriovenous malformations, and orthopedic procedures for overgrowth. All KT cases in this series occurred sporadically. We speculate that KT syndromes may be due to a somatic mutation for a factor critical to vasculogenesis and angiogenesis in embryonic development.

Pulmonary embolism in Klippel-Trénaunay syndrome of the upper limb

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Prenatal diagnosis and hemodynamic evaluation of Klippel-Trenaunay-Weber syndrome

Klippel-Trenaunay-Weber syndrome is a rare congenital soft-tissue anomaly which is characterized by the presence of multiple hemangiomata, arteriovenous fistulas and limb hypertrophy. We report the ultrasound findings in two cases of early prenatal diagnosis at 17 and 18 weeks of gestation. The pathogenesis of the syndrome and involvement of the cardiovascular system are discussed.

Application of the surface rendering technique of three-dimensional ultrasound in prenatal diagnosis and counselling of Klippel-Trenaunay-Weber syndrome

Klippel Trenaunay-Weber syndrome is a complex developmental disorder characterized by a triad of cutaneous haemangioma, varicosities of the body, and unilateral limb hypertrophy. We describe the prenatal diagnosis of Klippel-Trenaunay-Weber syndrome at 15 weeks' gestation using the surface rendering technique of three-dimensional ultrasound. The vivid three-dimensional images of the affected fetus are invaluable in prenatal diagnosis and parental counselling.

Prenatal diagnosis of Klippel-Trénaunay-Weber syndrome as a cause for in utero heart failure and severe postnatal sequelae

Ultrasound examination led to prenatal diagnosis of Klippel-Trénaunay-Weber syndrome complicated by early fetal congestive heart failure. The postnatal course was complicated by the Kasabach-Merritt syndrome of thrombocytopenia due to platelet consumption within the haemangioma. There was need for neonatal cardiopulmonary resuscitation and limb amputation.