Sclerotherapy Of Vascular Malformations Research Articles

Assessment of postoperative pain in children following sclerotherapy of vascular malformations: a retrospective single centre cohort study

BACKGROUND Inadequately controlled postprocedural pain following sclerotherapy in patients with vascular malformations is a well recognised problem. Reliable epidemiological data and risk factors associated with postprocedural pain in children are lacking. OBJECTIVES To evaluate and quantify postprocedural pain in children and identify possible risk factors based on characteristics of the patient, treatment, and medication. DESIGN A retrospective single centre cohort study. SETTING A tertiary single centre study in the Netherlands. PATIENTS Two hundred and nine chiuldren with ‘simple’ subtypes of congenital vascular malformation who had undergone sclerotherapy. PRIMARY OUTCOME MEASURE Quantifying inadequately controlled postprocedural pain. SECONDARY OUTCOME MEASURES Identifying potential patient and treatment characteristics associated with inadequately controlled postprocedural pain. RESULTS A total of 209 patients who underwent 679 procedures were included in this study. The mean age at first intervention was 11.8 ± 4.5 years. Inadequately controlled postprocedural pain was found in 34.8% of the 679 procedures. Venous malformations (VM) were the most prevalent subtype of vascular malformation (80%), followed by arteriovenous malformations (AVM) (14.6%) and lymphatic malformations (LM) (5.4%). The odds ratio (OR) (95% confidence intervals), and P values obtained from multivariable mixed effect logistic regression analysis for patient and treatment characteristics found to be associated with inadequately controlled postprocedural pain were: chronic use of analgesics (OR 2.74 (1.40 to 5.34), P = 0.003), treatment with ethanol (OR 2.39 (1.01 to 5.65, P = 0.05) or esketamine (OR 7.43 (1.32 to 41.81), P = 0.02). Patients treated with lauromacrogol (OR 0.42 (0.22 to 0.82, P = 0.01) and patients receiving intra-operative NSAIDs (OR 0.32, (0.12 to 0.85), P = 0.02) were less likely to experience inadequately controlled postprocedural pain. CONCLUSIONS Despite aiming to achieve best practice, the 34.8% incidence of unsatisfactory postoperative pain management in the children studied confirms that postprocedural pain after sclerotherapy is a common problem that requires further attention.

Utilizing Peripheral Nerve Blocks for Pain Management in Pediatric Patients during Embolization and Sclerotherapy for Vascular Malformations.

Vascular anomalies are a diverse group of abnormal blood vessel developments that can occur at birth or shortly afterward. Embolization and sclerotherapy have been utilized as a treatment option for these malformations but may cause moderate-to-severe pain. This study aims to evaluate the utilization of peripheral nerve blocks in opioid consumption, pain scores, and length of stay. A retrospective chart review was conducted at the UPMC Children's Hospital of Pittsburgh for all patients who underwent embolization and sclerotherapy between 2011 and 2020. Patient data were collected to compare opioid consumption, pain scores, and length of stay. In total, 854 procedures were performed on 347 patients. The morphine milligram equivalent per kilogram mean difference between groups was 0.9 (0.86, 0.95) with a p-value of <0.001. The pain score mean ratio was -1.17 (-2.2, -0.1) with a p-value of 0.027. The length of stay had an incident rate ratio of 0.94 (0.4, 2) and a p-value of 0.875. By decreasing opioid consumption and postoperative pain scores, peripheral nerve blocks may have utility in patients undergoing embolization and sclerotherapy while not clinically increasing the length of stay for patients. Their use should be individualized and carefully discussed with the interventional radiologist.

Sclerotherapy of Vascular Malformations in the Oral Cavity-Minimizing Postoperative Morbidity.

Vascular malformations (VMs) are a wide vascular or lymphatic group of lesions common on the head and neck. The objective of this study was to assess the efficacy and morbidity of sclerotherapy for the treatment of VMs in the oral and perioral area. Special attention was given to factors that may contribute to minimizing postoperative morbidity. Data from 25 patients (32 lesions) with oral VMs submitted to sclerotherapy with monoethanolamine oleate (EAO) were included. A structured form was used to collect data. An arbitrary score was determined to evaluate postoperative morbidity. Each of the following signs or symptoms received one point: pain, swelling, hematoma, ulceration, erythema, transient numbness, and transient itching. Pain and swelling were further divided into mild to moderate (1 point) and severe (2 points). Theoretically, the score was in the range of 0–9. Calculated scores ranged 0–4. The patients were further divided into two groups with scores of 0–1 denoting minimal morbidity (MIN) and 2–4 denoting significant morbidity (SIG). The number of lesions in each morbidity-score group were comparable (MIN 17and SIG 15). There were no statistically significant differences between the groups regarding age, number of applications, or average injection volume per mm lesion. Statistically significant differences were noted regarding gender (p = 0.05), lesion diameter (p = 0.030), total volume of first (p = 0.007) and second application (p = 0.05), and total injected volume (p = 0.03). Factors contributing to the risk for significant morbidity included being male, lesion diameter > 5 mm, volume > 0.3 mL per application, and total injected volume > 0.3 mL. A waiting time of 12 weeks prior to additional EAO application was required in 12 out of 29 lesions for clinical observation of complete regression. It was concluded that sclerotherapy with EAO as monotherapy is easy to apply, safe, and effective within a small number of sessions. Application of <0.3 mL EAO per session, and a waiting time of 12 weeks prior to the second application, would significantly minimize morbidity.

Combined Surgery and Intraoperative Sclerotherapy for Vascular Malformations of the Head/Neck

Vascular malformations (VMs) of the head and neck can lead to aesthetic problems as well as cranial nerve damage, airway compromise, and vision loss. Large VMs are typically managed surgically, with sclerotherapy or embolization performed in the perioperative period to decrease the risk of excessive blood loss and minimize the size of the VM. However, this initial treatment is frequently insufficient leading to excessive blood loss intraoperatively, poorer margin visualization for the surgeon, and decreased likelihood of complete resection. As a result, resections of large VMs are often performed in a multistage approach. This article introduces a new hybrid approach for the management of head and neck VMs entailing the use of an endovascular operating room where a neuroendovascular surgeon performs embolization or sclerotherapy intraoperatively as needed in conjunction with surgical excision. Three patients with large VMs in the facial region underwent successful use of the hybrid approach. The hybrid approach improved visualization, leading to complete resection in 1 patient and nearly complete resections (70% and 90%) in the other patients. The technique also helped minimize blood loss because only the youngest patient (23 months old) required a blood transfusion. Implications of these findings include the transition from a multistaged approach for large VMs to a single-stage approach. In addition, decreases in blood loss may allow for the development and use of minimal access techniques, leading to a decrease in visible scarring for patients. We suggest the consideration of the hybrid approach for large head and neck VMs.

Acute Pulmonary Emboli After Bleomycin Sclerotherapy for a Congenital Venous Malformation

SESSION TITLE: Pulmonary Vascular Disease Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Venous malformations (VM) are common congenital vascular abnormalities that progressively increase in size. They are associated with pain, cosmetic deformity, and bleeding complications. Sclerotherapy has been used in the treatment of symptomatically enlarging VM. Common sclerosing agents include ethanol, tetracycline, and bleomycin. Sclerotherapy has rarely been associated with pulmonary embolus (PE). We report the first case of PE complicating bleomycin sclerotherapy for a bleeding VM. CASE PRESENTATION: The patient is a 32 year old man with a large bleeding intraoral VM despite six prior sclerosing injections. The patient underwent out-patient bleomycin sclerotherapy under general anesthesia. Six days post-procedure, he was admitted with hemoptysis, dyspnea, and pleuritic chest pain. Oxygen saturation was 95%. Chest computed tomography with contrast revealed right middle and right lower lobar pulmonary emboli. Transthoracic echocardiogram demonstrated normal biventricular function and doppler ultrasound of upper and lower extremities was normal. The patient was treated with therapeutic anticoagulation and discharged on warfarin. An initial thrombophilia evaluation was normal. Hematology recommended 6 months of anticoagulant therapy with chemical prophylaxis for future sclerotherapy. DISCUSSION: Complications of sclerotherapy for VM include skin necrosis, infection, sensory neuropathy, and PE. While ethanol is the most effective sclerosant, bleomycin reportedly has fewer complications. Of note, sclerotherapy has only rarely been associated with PE and almost exclusively in the setting of esophageal or gastric varices. To the best of our knowledge, this is the first case report of PE complicating bleomycin sclerotherapy for VM. The underlying mechanism is not well described but likely related to intimal injury. Given the paucity of case reports and uncertain mechanism, it is unclear if periprocedural chemical prophylaxis would be indicated or effective for the prevention of venous thromboembolism. CONCLUSIONS: Sclerotherapy of vascular malformations can be complicated by venous thromboembolism. Clinicians should be aware of this rare, but potentially dangerous, association. Reference #1: Qui et al. Outcomes and complications of sclerotherapy for venous malformations. Vasc Endovascular Surg. 2013 Aug;47(6):454-61. Reference #2: Escardo et al. Pulmonary embolism after sclerotherapy treatment for variceal bleeding. Endoscopy. 2007; 39:E24-25. DISCLOSURE: The following authors have nothing to disclose: Bishoy Zakhary, Ezra Dweck, Leopoldo Segal, David Steiger No Product/Research Disclosure Information

Sclerotherapy for vascular malformations: Complications and a review of techniques to avoid them

Interventional radiology has a principal role frequently replacing surgery in the multidisciplinary management of vascular malformations. Having noticed an initial high rate of complications, we examined our early experience to study in detail the outcomes and risks. We also present a review of techniques to reduce these complications. Data were collected during a 5-year period on patients who had completed treatment. The two sclerosants used were either 100% alcohol or 3% sodium tetradecyl sulphate (STS) as sole agents, or in combination. We graded early clinical and radiological outcomes. Binary logistic regression analysis was carried out for variables (age, type of vascular malformation and number of sclerotherapy sessions) that may predict the occurrence of complications. Twenty-four patients (11 males and 13 females) completed treatment during this period and were the subject of this review. There were a total of 46 sessions with an average of two (range: one to five). The mean and median ages were 36.2 and 38 years, respectively. Nineteen patients had venous malformations and five had lymphatic malformations. Most of the vascular malformations were in the head and neck region (66.7%). Although the overall early results were favourable (21 out of 24 patients had partial or complete resolution clinically and radiologically), there were four nerve-related and three skin-related complications. Using alcohol alone (13 patients, 24 sessions) there were one skin and three nerve injuries; with STS alone (five patients, 19 sessions) there was one skin complication; and when in combination (six patients, three sessions) one nerve and one skin complications. More complications were seen with the use of alcohol, including all the nerve-related injuries, prompting a change of practice to favour STS as the primary agent, especially for head and neck lesions.

Sclerotherapy for Vascular Malformations in the Oral and Maxillofacial Region: Treatment and Follow-Up of 66 Lesions

The aim of the present study was to relate the use of 5% monoethanolamine oleate in sclerotherapy for vascular malformations and to suggest a protocol for its use. A total of 53 patients with 66 vascular malformation lesions were treated with an intralesional injection of 5% monoethanolamine oleate at 0.1 mL/cm of lesion with at least a 15-day interval and as many as 4 applications. A descriptive statistical analysis was performed using SigmaPlot, version 9.0, software. The treatment with the protocol suggested was effective in 65 cases, and in 1 case, surgical intervention was required. Sclerotherapy was effective in the treatment of vascular malformations, and the method chosen was adequate for lesion resolution without complications.

Basic fibroblast growth factor is beneficial for postoperative color uniformity in split-thickness skin grafting

Color changes of visible and exposed body surfaces, such as the face and extremities, after burn injury or surgery, such as skin grafting, flap, or sclerotherapy for vascular malformations, are sometimes a concern. The consequences reduce the satisfaction of both patients and physicians. An easy and reproducible method has not yet been established for an objective analysis of color changes; therefore, we tested a hand-held color analyzer (NF-333; Nippon Denshoku Co. Ltd) with data transport to a computer database and analysis software for posttreatment skin color change. The parameters included L, a, and b, which measure clarity, red, and yellow, respectively. Two groups were prospectively divided with 20 (11 females and nine males) patients per group. One group received skin grafting plus basic fibroblast growth factor (bFGF) spray daily and the other group received only skin grafting. The patients were randomized by the date of their first visit to our hospital. Patients were treated with bFGF on odd days, while patients who came on even days were included in the non-bFGF-treated group. The donor site for skin grafting was the lateral thighs and the thickness was similar in both groups. The results were compared at 1-year posttreatment follow-up. Clinical and objective assessments of the scars were performed 1 to years after complete healing. Color change differentials in comparison with the surrounding skin were lower with bFGF treatment in all parameters (p<0.01), along with clinical assessment with the Vancouver Scar Scale; therefore, the treatment contribute to a better color match with skin grafting postoperatively.

Classification and Sclerotherapy for Vascular Malformations

Classification and Sclerotherapy for Vascular Malformations

An injectable tissue-engineered embolus prevents luminal recanalization after vascular sclerotherapy

Background/Purpose Sclerotherapy for vascular malformations is often limited by luminal recanalization. This study examined whether an injectable tissue-engineered construct could prevent this complication in a rabbit model of venous sclerotherapy. Methods Ethanol sclerotherapy of a temporarily occluded jugular vein segment was performed in 46 rabbits, which were then divided into 3 groups. Group I (n = 16) had no further manipulations. In groups II (n = 15) and III (n = 15), 0.5 mL collagen hydrogel was injected intraluminally, respectively, devoid of and seeded with autologous fibroblasts. At 1, 4, and 20 to 24 weeks postoperatively, vein segments were examined for patency and resected for histological evaluation. Statistical analysis was by Fisher's Exact test. Results All vein segments were occluded at 1 and 4 weeks in all groups, despite histological evidence of progressive endothelial ingrowth. However, at 20 to 24 weeks, angiography demonstrated restoration of vessel patency in groups I (3/6) and II (3/5), but not in group III (0/6; P = .043), in which histology confirmed an obliterated lumen for all vessels. Conclusion An injectable, fibroblast-based, engineered construct prevents midterm to long-term recanalization in a leporine model of vascular sclerotherapy. This novel therapeutic approach may prevent recurrence of vascular malformations after sclerotherapy, thus reducing the need for repeated procedures and morbid operative resections.