Low-flow Vascular Malformations Research Articles

Abstract No. 386 Comparing pre-procedure imaging versus direct stick venography for low flow vascular arterio-venous malformations

Vascular malformations represent rare developmental errors during vasculogenesis with widely varying presentations. Non-invasive modalities such as duplex ultrasonography, magnetic resonance imaging (MRI), and to a lesser extent computed tomography angiograph (CTA) are the mainstays of pre-procedure imaging. Different classification systems developed for venous malformation have been used to help guide management of arteriovenous malformations. Direct stick phlebography is a modality used for both diagnostic and treatment purposes in the management of low-flow arteriovenous malformations.

Surgical management of pediatric intracranial cerebral cavernous malformations: a 10-year single-center experience.

Cerebral cavernous malformations (CCMs) are low-flow vascular malformations made up of dilated vascular spaces without intervening parenchyma that can occur throughout the central nervous system. CCMs can occur sporadically or in familial forms. Presentation is diverse, ranging from incidental discovery of asymptomatic CCMs to drug-resistant epilepsy and hemorrhages. We describe the surgical management of CCMs in pediatric patients at Bambino Gesù Children's Hospital in Rome over the last 10 years. The cases have been stratified based on the clinical presentation and the relevant literature is discussed accordingly. We discuss the rationale and technique used in these cases based on their presentation, as well as the generally positive outcomes we achieved with early surgical management, use of intraoperative ultrasound (ioUS) and intraoperative neuromonitoring. Surgical management of pediatric CCMs is a safe and effective strategy, low rates of postoperative morbidity and partial resection were observed.

Somatic activating BRAF variants cause isolated lymphatic malformations.

SummarySomatic activating variants in PIK3CA, the gene that encodes the p110α catalytic subunit of phosphatidylinositol 3-kinase (PI3K), have been previously detected in ∼80% of lymphatic malformations (LMs).1,2 We report the presence of somatic activating variants in BRAF in individuals with LMs that do not possess pathogenic PIK3CA variants. The BRAF substitution p.Val600Glu (c.1799T>A), one of the most common driver mutations in cancer, was detected in multiple individuals with LMs. Histology revealed abnormal lymphatic channels with immunopositivity for BRAFV600E in endothelial cells that was otherwise indistinguishable from PIK3CA-positive LM. The finding that BRAF variants contribute to low-flow LMs increases the complexity of prior models associating low-flow vascular malformations (LM and venous malformations) with mutations in the PI3K-AKT-MTOR and high-flow vascular malformations (arteriovenous malformations) with mutations in the RAS-mitogen-activated protein kinase (MAPK) pathway.3 In addition, this work highlights the importance of genetic diagnosis prior to initiating medical therapy as more studies examine therapeutics for individuals with vascular malformations.

Is there a place for prophylaxis with DOACs in Klippel-Trenaunay syndrome and other low-flow vascular malformations with intravascular coagulopathy and thromboembolic events?

Although Direct Oral AntiCoagulants (DOACs) are first choice treatment in venous thromboembolism (VTE), in rare conditions, such as vascular anomalies and especially low-flow vascular malformations (VM), where the increased risk of thromboembolic events (TEE) is becoming increasingly evident, prophylaxis with DOACs has not yet been implemented [1,2].

MR-guided Cryoablation for the Treatment of Symptomatic Pedal Vascular Malformations

Objective: Vascular malformations are benign vascular anomalies characterized by abnormally developed arterial, venous, and lymphatic structures, which are often symptomatic. Historical and current treatment techniques include intravascular embolization/sclerosis and surgical resection. While these techniques have proven to be successful at managing and treating these types of lesions, these techniques are not without risk, especially in the small spaces of the hands and feet. Cryoablation for the treatment of low-flow vascular malformations is a new and evolving technique. We present five cases of symptomatic pedal vascular malformations treated with MR guided cryoablation, which provides encouraging safety and feasibility results for these difficult to treat lesions. Methods: A retrospective review of patients who had undergone MR-guided cryoablation of their pedal vascular malformations between January 2016 and January 2020 was performed. Results: Five cryoablations were completed without immediate complication. All patients reported markedly decreased pain corresponding to the treated area and improvement in their ability to return to a more active lifestyle. Two patients experienced mild transient numbness which resolved by 2–3 months and one patient experienced a transient motor and sensory neuropathy which resolved by 6 months. Conclusion: We present five cases of successful MR-guided cryoablation of symptomatic pedal venous malformations. Many of the patients included in this review failed conservative and other interventional/surgical treatments. The treatment options for this patient cohort can be limited given small space within the plantar aspect of the foot. Cryoablation of these lesions can be performed safely especially under continuous MRI monitoring. Level of Evidence: Case series (Level 4)

Single Centre Experience of Sirolimus Therapy in Low Flow Head and Neck Vascular Malformations: Venous Diseases (Including Malformations)

Introduction: Embolosclerotherapy and surgical interventions for complicated and refractory head and neck vascular malformations can be challenging owing to the complex anatomy and presence of vital structures, including the airway and major nerves. Inhibiting mammalian target of rapamycin (mTOR) prevents downstream protein synthesis, cell proliferation, and angiogenesis. Recently, studies have shown that sirolimus, an mTOR inhibitor, is clinically efficacious in the treatment of some low flow vascular malformations but with potential side effects.

TOPICAL TACROLIMUS 0.1% FOR TREATMENT OF CUTANEOUS MICROCYSTIC LYMPHATIC MALFORMATIONS

Microcystic lymphatic malformations as described in the international literature form a subgroup of low-flow congenital vascular malformations (VM) resulting from irregular embryological development. Microcystic lesions normally manifest as an accumulation of lymph- and blood-filled vesicles that, when externalized, cause skin maceration with consequent pain and potential infection resulting in the impairment of the patient's quality of life. There is no consensus on a standardized algorithm nor clear guidelines for successful treatment of this type of lymphatic malformation, and treatment options employed often result in ambivalent and transient outcomes with a high rate of recurrence. The topical formulation of tacrolimus is a well-known FDAapproved anti-T cell agent that was recently identified as a potent activator of ALK1, which is involved in several processes and functions including angiogenesis. We investigated if topical administration of tacrolimus may be an effective therapy for directly targeting cutaneous microcystic lymphatic malformations as a complement to systemic treatment. The study enrolled four patients with cutaneous microcystic lymphatic malformations: three male (ages: 13,15,18) and one female (age: 30). Two of the patients presented lesions on their backs, one patient on the left hand and one on the left lower limb. All four patients received treatment with topical tacrolimus 0.1% twice a day for 10 weeks on a previously selected area for application. Weekly clinical follow-ups were conducted along with close physician-patient contact. All patients displayed a satisfactory response after treatment. Lymphorrhea and bleeding were stopped in all cases and the esthetic aspect of lesions improved in two patients. To date, all patients presented no clinically significant changes to the size or extension of the lesion. Topical tacrolimus treatment is a promising and reasonable option for microcystic lymphatic malformations. Our results encourage further exploration in larger populations with the consideration that it is a safe and effective alternative or complementary therapy to systemic treatment.

Diagnostic Accuracy of SWAN in the Diagnosis of Low-Flow Brain Vascular Malformations in Childhood

Abstract Purpose The main objective of this study is to demonstrate the diagnostic accuracy of susceptibility-weighted angiography (SWAN) in the diagnosis of slow-flow cerebral vascular malformations, especially developmental venous anomaly (DVA). We also aimed to determine the prevalence of DVAs identified by SWAN at 1.5 T. Methods We retrospectively evaluated 1,760 axial SWAN images for the diagnosis of low-flow vascular anomaly. Among them were 305 patients who underwent contrast-enhanced examination due to different indications. Postcontrast images were analyzed by different radiologists who were blinded to patients. The presence of DVA and other features such as location, length, depth, and direction of drainage vein was evaluated. Results Twenty-six patients with DVA had both SWAN and postcontrast images. There were four false-negative patients with SWAN. The sensitivity of the SWAN sequence was 84.6%. In addition, totally 77 DVA (4.36%), 2 capillary telangiectasia (0.11%), and 2 cavernous malformations (0.11%) were detected in 1,760 patients. Conclusion SWAN is an effective method for the diagnosis of developmental venous anomalies and other low-flow cerebral vascular malformations. Especially in the pediatric age, susceptibility-weighted imaging sequences are useful to limit contrast use.

The cerebrofacial metameric syndromes: An embryological review and proposal of a novel classification scheme.

The cerebrofacial metameric syndromes are a group of congenital syndromes that result in vascular malformations throughout specific anatomical distributions of the brain, cranium and face. Multiple reports of patients with high-flow or low-flow vascular malformations following a metameric distribution have supported this idea. There has been much advancement in understanding of segmental organization and cell migration since the concept of metameric vascular syndromes was first proposed. We aim to give an updated review of these embryological considerations and then propose a more detailed classification system for these syndromes, predominately incorporating the contribution of neural crest cells and somitomeres to the pharyngeal arches.

Utility of Intraprocedural Cross-sectional Imaging in the Treatment of Low Flow Vascular Malformations

There is a high recurrence rate following sclerotherapy of low-flow vascular malformations. Conventional treatment utilizes fluoroscopy and ultrasound to assess the diffusion of the sclerosing agent during therapy. These modalities give a limited 2-dimensional image. Employing intraprocedural cross sectional imaging (ICSI) has the potential to give a 3-dimensional assessment of the sclerosant diffusion. The purpose of this study is to evaluate the impact of ICSI on immediate outcomes of sclerotherapy of low-flow vascular malformations.

Efficacy and safety of oral sirolimus for high-flow vascular malformations in real clinical practice.

Vascular malformations are a complex pathology with few treatment options. In previously published studies, oral sirolimus (rapamycin) has shown promising results in the treatment of low-flow vascular malformations, but its usefulness in high-flow vascular malformations is controversial. To evaluate the efficacy and safety of sirolimus for the treatment of high-flow vascular malformations in real-life practice. In a unit specializing in vascular anomalies, patients treated with oral sirolimus for high-flow vascular malformations were located by consulting the drug dispensations. Reviewing the electronic medical records, data on patient demographics, vascular malformation characteristics, treatments, toxicity and clinical course were collected and statistically analysed. Nine patients with vascular malformations were included: eight had arteriovenous malformation and one had arteriovenous fistula. Six of these malformations were isolated while three were part of a syndrome. Sirolimus was initiated at a dosage of 1-4 mg/day to be taken as a single dose. Partial response was observed in eight of the nine patients (88.9%) with high-flow vascular malformation, while worsening was observed in the remaining patient. The treatment was well tolerated and at the most recent follow-up, five patients remained on treatment with oral sirolimus. Our results show that oral sirolimus is a well-tolerated therapeutic option, with an excellent safety profile, which can be useful in the long-term stabilization of patients with high-flow vascular malformations. Single-daily dosage may improve long-term adherence to treatment without worsening its effectiveness.

Incidence of major complications from embolo-sclerotherapy of head and neck vascular malformations in a single specialist centre.

Current data on the nature and rate of major complications for embolo-sclerotherapy (EST) of vascular malformations are scarce. However, even fewer studies focus on vascular malformations specific to the head and neck, which confer an increased specific risk of airway compromise, neurologic and ophthalmologic injury. More understanding is required surrounding the type and incidence of complications to improve treatment planning and informed consent. Therefore, this study aimed to review major complications secondary to EST of head and neck vascular malformations over a 5-year period in a single specialized multidisciplinary centre for vascular anomalies. All interventions were decided by the multidisciplinary team. Demographic, procedural and complication data between 1st January 2013 and 31st December 2017 were prospectively documented in a dedicated database and analysed. EST of high-flow vascular malformations (HFVMs) was performed by selective catheter angiography or direct injection, and by direct injection only for low-flow vascular malformations (LFVMs). Major complications were defined as any tissue or functional damage caused by direct injection, distal embolization or tissue reaction and were decided by the multidisciplinary team. Forty-eight patients (median age of 35 years; range of 14-70 years; 18 men and 30 women) had 100 EST procedures for head and neck vascular malformation. Of these, 14 patients had EST for HFVM and 34 patients for LFVM, total 43 and 57 procedures, respectively. Overall, five patients with HFVM developed major complications from EST when compared with two patients with LFVM (p = 0.0167). Two patients required pre-emptive tracheostomy due to risk of post-operative airway compromise. Overall, seven (14.6%) patients experienced major complication from EST. In the HFVM group, major complications from EST occurred in five patients; four cases of tissue ulceration and necrosis (two needed debridement, one healed with resultant fibrosis that impeded speech and one resolved spontaneously) and one post-procedural airway compromise requiring tracheostomy. Meanwhile, in the LFVM group, major complications occurred in two patients; one case of severe necrosis involving the alar cartilage, lip and cheek requiring debridement and reconstruction under plastics and one simple cellulitis. No patients sustained stroke or vision impairment. EST is relatively safe for head and neck vascular malformations in a high-volume experienced centre. Our major complication rate of 14.6% per patient (35.7% for HFVM; 5.9% for LFVM) or 7% per procedure (11.6% for HFVM; 3.5% LFVM) compares favourably with published data from other centres. These data will improve treatment planning and informed consent for EST for both HFVM and LFVM of the head and neck.

Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report

Cavernous malformations (CMs) are angiographically occult low-flow vascular malformations that infrequently involve the optic pathway and the hypothalamus (OPH). A 23-yr-old male presented with bitemporal hemianopia due to chaismal apoplexy. Imaging revealed a CM involving the OPH. The CM was resected by an extended endonasal approach. The patient had improvement in his visual field defects, and postoperative magnetic resonance imaging (MRI) revealed a gross total resection of the CM. This case demonstrates the surgical technique of endoscopic endonasal resection of a CM involving the optic pathway.

Patients with Congenital Low-Flow Vascular Malformation Treated with Low Dose Sirolimus

IntroductionPatients with congenital vascular malformations often suffer from an impaired quality of life (QoL) because of pain and functional disabilities. Previous studies have shown that the mTOR inhibitor sirolimus can reduce complaints and improve QoL in some patients. High target levels of sirolimus of 10–15 ng/ml were well tolerated; however, in a relative high percentage of patients sirolimus caused serious adverse events (AEs).MethodsA case series of 12 patients with therapy-resistant low-flow vascular malformations was treated with sirolimus, using low target levels of 4–10 ng/ml. Efficacy of sirolimus was evaluated in regard to pain symptoms using the visual analogue scale/numeric rating scale and patients reported QoL. To rule out a placebo effect of sirolimus, sirolimus was stopped after a certain time point and reintroduced as soon as complaints returned. Adverse events were closely monitored and graded using the Common Terminology Criteria for Adverse Events (CTCAE) grading.ResultsAn improvement in symptoms was seen in 92% (n = 11/12) of patients. In nine patients pain complaints returned. Seven out of nine of them (78%) again experienced a reduction of symptoms after restarting sirolimus treatment. Despite low target levels, these response rates are comparable to those found in the literature using higher target levels of sirolimus. However, significantly less serious AEs were observed with low dose sirolimus, suggesting low dose sirolimus might be safer. Unfortunately, young adolescent female patients developed serious menstrual disturbances during treatment with low dose sirolimus. We describe this adverse event for the first time in patients with congenital vascular malformations and this might be specifically related to low dose sirolimus.ConclusionsLow dose sirolimus showed a high efficacy in patients with therapy-resistant and low-flow malformation, with a lower incidence of serious adverse events. At the same time a new adverse event, namely menstrual cycle disturbance, was observed in young adolescents, indicating the need for caution when sirolimus is given. This is extremely relevant to patients with low-flow vascular malformation, who are likely to require lifelong treatment for their condition.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01758-y.

Abstract No. 197 Using intraoperative neurophysiologic monitoring to prevent peripheral nerve injury during embolization of low-flow vascular malformations

To assess the efficacy of intraoperative neurophysiologic monitoring as a method to minimize iatrogenic injury of peripheral nerves during the embolization of low-flow vascular malformations With IRB exemption and HIPAA compliance, the electronic medical record was searched with the search term venous malformation (VM), lymphatic malformation (LM), and mixed vascular malformations (MVM). We derived a study cohort of 50 patients with low-flow vascular malformations treated with percutaneous embolization using sclerosants such as Ethanol, Sotradecol, Bleomycin, and Doxycycline performed from 2004 to 2019 and who received intra-operative nerve monitoring for lesions that are adjacent to one or more peripheral nerve(s). Major complications were defined as those necessitating unplanned hospitalization, prolonging hospital stay, or additional interventions. Minor complications were those managed conservatively without additional treatment. In the study cohort of 50 patients (mean age 30.1 years, range 5-71, 60% female, 59% pediatric) with low-flow vascular malformations (VM 74%, LM 17%, MVM 4%) who underwent percutaneous embolization with intraoperative neurophysiologic monitoring of the adjacent nerve(s), the mean follow-up was 5.56 years (range < 1-14.8 years). Including re-treatments, 319 sites located in the facial (37%), neck (16%), upper extremity (27%), lower extremity (12%), oral cavity (2%), chest (2%), back (2%), and gluteal (2%) regions were targeted by sclerotherapy. There was a minor complication rate of 2.5% (n = 2/80, superficial skin burn), and no major complication. Peripheral nerves with motor and/or somatosensory functions were monitored and included facial (34%), median (15%), ulnar (15%), peroneal (11%), posterior tibial (10%), radial (7%), popliteal (2%), and hypoglossal (2%) nerves and the brachial plexus (2%). Intraoperatively, abnormal neurophysiologic findings were noted in 35% of the treatment sessions and 9% of all sessions were terminated early due to significantly diminished electrophysiologic responses. Ethanol was the sclerosant used in all early terminated sessions (n = 8/85). No patient developed long-term neurologic impairment Intraoperative neuromonitoring may improve the safety of vascular embolization procedures by providing a real-time assessment of any ongoing damage and facilitate intra-procedural planning.

Single Center Experience of Sirolimus Therapy in Head and Neck Low-flow Vascular Malformations.

Recently, studies have shown that sirolimus is clinically efficacious in the treatment of some low-flow vascular malformations (LFVM). This study aimed to assess the efficacy and safety of sirolimus in treating complex head and neck (H&N) LFVM that were challenging and/or refractory to standard treatment. Each patient had baseline and 6-months assessments consisting of clinical history and examination, quality of life (QoL) questionnaires, laboratory investigations, MRI and medical photography. Patients were followed up 1-week and then 1-monthly for 6-months. Wilcoxon signed-rank test was used to compare pre-and 6-months treatment in all 8 domains of RAND 36-Item Short Form Health Survey (SF-36), hospital anxiety and depression scale (HADS), and visual analog score for pain (VAS-P). P < 0.05 was considered significant. Seven patients (median age 43 years, range 23-65 years) were recruited. Six patients completed the six-months course of therapy with 1 patient withdrawing due to intolerable side effects. All six patients reported reduction of swelling with and without other symptom improvement related to the vascular malformations while on treatment. However, at 1-month review after discontinuation of sirolimus, 5 patients reported return of initial symptoms. Overall, patients demonstrated an improvement in QoL six-months treatment but there was no statistical significance (P > 0.05) in all 8 domains of SF-36, HADS and VAS-P. Five patients demonstrated a minimum 10% decrease in lesion size six-months treatment (median 21%, range 13-40%). A Wilcoxon signed-rank test showed that sirolimus treatment did elicit a statistically significant change in lesion size in either direction (Z = -1.992, P = 0.046). The most common side effects found were dyslipidaemia (n-4) and mouth ulcers (n = 2). In our preliminary experience, sirolimus is effective and safe in treating patients with complex H&N LFVM. This provides an alternative treatment where standard treatment is challenging and/or refractory.

Quality of life and mental health of patients with vascular malformations in a single specialist center in the United Kingdom

ObjectivePatients with vascular malformations suffer from chronic debilitating symptoms that have been shown to contribute negatively to their quality of life (QoL) and mental health. Despite this, the current literature evaluating the QoL and mental health of patients with vascular malformations remains scarce. Our aim was to evaluate the QoL and mental health of patients with vascular malformations. MethodsWe prospectively analyzed the validated health-related QoL (HRQoL) questionnaires: the RAND Health Care 36-Item Short Form Survey (SF-36), Hospital Anxiety and Depression Scale (HADS), and visual analogue score for pain reported by 253 patients with vascular malformations in a specialist center of vascular anomalies in the UK over 2 years. ResultsPatients with vascular malformations reported significantly poorer SF-36 scores in all domains compared with the UK general population. Patients with low-flow vascular malformations and arteriovenous malformations reported little variations in SF-36, HADS, and visual analogue score for pain scores. No significant association was found between age and any of the health-related QoL scores, other than the physical functioning in SF-36. Female patients reported significantly lower physical and social functioning of SF-36 and worse HADS-Depression than their male counterparts. Patients with syndromic vascular malformations reported significantly lower SF-36 scores in role–physical, role–emotional and bodily pain than nonsyndromic vascular malformations. ConclusionsThis study concluded that patients with vascular malformations reported worse QoL than the UK general population. Therefore, the assessment and management of QoL and mental health should be incorporated into the overall treatment strategies of patients with vascular malformations.

Unilateral clubbing-like digital thickening as a clinical manifestation of low-flow vascular malformations: a series of 13 cases.

Digital clubbing is a well-known clinical sign characterized by thickening of the distal phalanges of the fingers and toes. Unilateral clubbing occurs less frequently. A previous report showed for the first time two cases of unilateral clubbing as a clinical manifestation of lower limb venous malformation. The objective of the present study is to describe a series of 13 patients with a low-flow vascular malformation where a clubbing-like unilateral digital thickening is also observed. All patients were retrospectively included after reviewing clinical photographs from a vascular malformations database. A total of 13 patients with low-flow vascular malformations were included in this study. The mean age at diagnosis was 11years (range 5-26years) with a female predominance (nine patients). The most frequent vascular malformation collected was a blue rubber bleb nevus syndrome in four patients, followed by common venous malformations in three patients. All patients characteristically exhibited a clubbing-like digital thickening. Seven patients had foot involvement and six patients hand involvement. Although the number of cases is limited, our study is the first series of cases where a clubbing-like digital thickening is described in patients with a low-flow vascular malformation. The unilateral presence of clubbing or pseudoclubbing should lead to the suspicion of an underlying vascular malformation.

Transcatheter Embolo-sclerotherapy of High Flow Arteriovenous Malformations

Background: Vascular malformations can be classified according to endothelial characteristics and flow dynamics of the lesions, on which the principles of treatment are based. Percutaneous injection of sclerosing agents such as ethanol or sodium tetradecyl sulfate is the mainstay treatment for the more prevalent low-flow or venous vascular malformations. In contrast, symptomatic high-flow arteriovenous malformation (AVM) generally requires transcatheter embolo-sclerotherapy with or without surgery to control the disease process. Objective: To evaluate the safety and efficacy of endovascular management of high flow arteriovenous malformation by embolization and sclerotherapy. Patients and methods: This study was conducted at Mansoura University Hospitals, we included a total of 18 cases diagnosed with high flow AVM. All cases were subjected to complete history taking, thorough physical examination, and routine laboratory investigations. Also, duplex ultrasound (US) and computed tomography (CT) angiography were ordered for all cases. Results: The mean age of the included cases was (26.73 years (range, 8 – 60 years). Males represented 61.11% of these cases, while the remaining patients were females. As regard the clinical result, success was achieved in 16 cases (61.11%). Only two cases had poor clinical result (11.11%). Transient ischemia was encountered in 2 cases (11.11%). Other complications included ulceration (5.56%), foot gangrene (5.56%), hand ischemia with amputation (5.56%), contracture scar (5.56%), and necrosis with transient PE (6.7%). With a mean follow up period of 26 months (range, 6 – 36 months), 16 cases showed very good outcome (88.89%), one case had good outcome (5.56%), while the remaining case had poor outcome (5.56%). Conclusion: Embolo-sclerotherapy appears to be safe and effective intervention for high flow arteriovenous malformations.

Diode laser for the treatment of a high flow lip vascular malformation.

About 50% of vascular malformations are located at the head and neck region where they can usually be associated with functional and/or aesthetic limitations. Laser treatment has proven to be effective in treatment of small low-flow vascular malformations, but little is known about the use of this therapy for high-flow larger arteriovenous malformations (AVMs). A congenital high-flow vascular malformation of the upper lip had to be treated because it was causing functional impairment and deformity which were affecting the quality of life. The mainstay of treatment is surgical therapy after embolization of the lesion, but the treatment of high-flow lesions is difficult because of the high risk of mortality and morbidity. The lesion was then treated with transmucosal diode laser applications in multiple sessions. The lesion progressively reduced in dimension without any sign of recurrence after multiple sessions of transmucosal diode laser applications. The clinical examination and the ultrasound scan performed four years after the last treatment demonstrated that no complications or further recurrence occurred. Multiple sessions of diode laser application can be a safe, effective and minimally-invasive treatment for oral mucosa vascular malformations, even if characterized by high flow.