Invited commentary

Abstract

In this article, the authors describe the successful management of 16 patients with relatively sudden enlargement of a venous malformation (VM) due to acute hemorrhage. This represents a small subset of patients with VMs since the majority of VMs do not develop intra-lesion hemorrhage. The authors report good results using a combination of ethanol and bleomycin as the sclerosing agent. While the use of the powerful sclerosing agent absolute ethanol is quite well accepted for treating more aggressive arteriovenous malformations, its use in VM is more limited. This is because of serious potential complications reported with its use, including acute complications of nerve palsy or even cardiopulmonary arrest.1Lee B.B. Kim D.I. Huh S. Kim H.H. Choo I.W. Byun H.S. et al.New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation.J Vasc Surg. 2001; 33: 764-772Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar, 2Lee B.B. Do Y.S. Byun H.S. Choo I.W. Kim D.I. Huh S.H. Advanced management of venous malformation with ethanol sclerotherapy: mid-term results.J Vasc Surg. 2003; 37: 533-538Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar Therefore, many have begun to consider the use of less dangerous sclerosing agents, such as detergent-based foam, especially for less aggressive VMs, including those with transdermal extension in which there is a higher risk for complications from ethanol injection. Although foam sclerotherapy is likely less effective than ethanol, the complication rate is lower, and if VMs recur, or are only partially treated initially, they can be re-treated with foam sclerotherapy with fewer overall complications. The authors attempted to reduce the risk involved with ethanol injection of the VM by mixing it with bleomycin. However, it is difficult to judge the contribution of bleomycin to the overall treatment outcome since the ethanol was given first to block the draining veins; regardless of its amount, there is substantial risk of the vascular spasm induced by the ethanol before bleomycin begins to work, reducing its effective contact with the endothelial cells. Bleomycin was used extensively to various lymphatic malformations (LMs) with excellent result for the macrocystic lesions in particular.3Mathur N.N. Rana I. Bothra R. Dhawan R. Kathuria G. Pradhan T. Bleomycin sclerotherapy in congenital lymphatic and vascular malformations of head and neck.Int J Pediatr Otorhinolaryngol. 2005; 69: 75-80Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 4Orford J. Barker A. Thonell S. King P. Murphy J. Bleomycin therapy for cystic hygroma.J Pediatr Surg. 1995; 30: 1282-1287Abstract Full Text PDF PubMed Scopus (149) Google Scholar It still remains a major option when OK-432 (Chugai Pharmaceutical, Tokyo, Japan), also known as picibanil, which is made with attenuated streptococcal exotoxin, is not available for the LM.5Ogita S. Tsuto T. Deguchi E. Tokiwa K. Nagahima M. Iwai N. OK-432 therapy for unresectable lymphangiomas in children.J Ped Surg. 1991; 26: 263-270Abstract Full Text PDF PubMed Scopus (141) Google Scholar, 6Lee B.B. Kim Y.W. Seo J.M. Hwang J.H. Do Y.S. Kim D.I. et al.Current concepts in lymphatic malformation (LM).J Vasc Endovasc Surg. 2005; 39: 67-81Crossref Scopus (90) Google Scholar However, we have found bleomycin is generally less effective when the LM is mixed with the VM. Furthermore, the potential concern for pulmonary fibrosis as a long-term complication of bleomycin remains to be answered especially when it is injected to the VM/venous system. This potential long-term concern has led us not to use bleomycin for VM treatment. In summary, while the authors have reported good results without acute side effects using a combination of ethanol and bleomycin for treating acute hemorrhage within VMs, I believe that foam sclerotherapy should be the sclerosing agent used in these cases, in order to reduce potential complications, accepting a higher recurrence rate with the knowledge that the VM can be retreated.7Lee B.B. Bergan J. Foam sclerotherapy: a textbook.in: Bergan J. Cheng V.L. Chapter 12. Transition from alcohol to foam sclerotherapy for localized venous malformation with high risk. The Royal Society of Medicine Press Ltd, London, UK2008: 9129-9139Google Scholar, 8Yamaki T. Nozaki M. Fujiwara O. Yoshida E. Duplex-guided foam sclerotherapy for the treatment of the symptomatic venous malformations of the face.Dermatol Surg. 2002; 28: 619-622Crossref PubMed Scopus (55) Google Scholar Patients with intralesional hemorrhage in venous malformations: Diagnosis and embolosclerotherapyJournal of Vascular SurgeryVol. 49Issue 2PreviewVenous malformations (VMs) are common congenital benign lesions characterized by slow progression. However, intralesional hemorrhage can result in sudden enlargement of the lesions, which, though uncommon clinically, brings difficulties in diagnosis and treatment. The purpose of this study is to explore the clinical features and diagnosis modality of intralesional hemorrhage in VMs and present our experience with embolosclerotherapy. Full-Text PDF Open Archive