Venous Lakes Research Articles

Multiwavelength Laser Treatment of Venous Lakes

Venous lakes (VLs) are common benign ectasias in the upper dermis, usually observed in older people. Different treatment strategies have been described as useful, such as cryosurgery, excision, and various types of laser. We report our experiences using a multiwavelength laser, which has not been previously described. Thirty-nine VLs in 30 patients were treated. Treatment with 595-nm pulsed-dye laser was conducted at 20 ms and 10 J/cm(2), followed by 1,064-nm neodymium-doped yttrium aluminum garnet laser at 20 ms and 70 J/cm(2). Complete resolution was observed in 38 lesions (95%). No complications after treatment were noted. One case developed a small scar. Multiwavelentgh laser (595 nm; 1,064 nm) provides a safe, fast, and effective option in the treatment of VLs.

Clinical Study of Sclerotherapy of Maxillofacial Venous Malformation Using Absolute Ethanol and Pingyangmycin

The purpose of this study was to evaluate the outcomes of sclerotherapy of maxillofacial venous malformations by use of absolute ethanol and pingyangmycin (bleomycin A(5) hydrochloride). We treated 23 consecutive patients with maxillofacial venous malformations by sclerotherapy with a combination of absolute ethanol and pingyangmycin under local anesthesia. The size of the lesions ranged from 2 cm x 2 cm to 12 cm x 10 cm. Venography showed the presence of large venous lakes. Venograms were obtained during the first procedure before and after injection of absolute ethanol (0.5-2.5 mL) to confirm the site of the nidus and assess the effect of sclerosis of the nidus and draining veins. Subsequently, 8 to 16 mg of pingyangmycin dissolved in 40 mL of saline solution was infused into the nidus by a dynamic infusion pump at a rate of 1 mL/min. If necessary, this procedure was repeated once in 2 or 4 weeks. The clinical outcomes and complications were evaluated. The duration of follow-up ranged from 6 to 37 months, with a mean of 20.3 months. Only 1 procedure was required in 3 patients, and the procedure was required to be repeated twice in 9 patients, 3 times in 7, and 4 times in 4. All the patients were satisfied with the treatment results, and excellent clinical results were obtained in 9 patients. There was no skin necrosis or nerve damage. Percutaneous sclerotherapy with the combined use of absolute ethanol and pingyangmycin is a safe and effective treatment for maxillofacial venous malformations.

Lateral lakes of Trolard: anatomy, quantitation, and surgical landmarks

There is scant and conflicting information in the literature regarding the lateral lacunae, or lateral lakes of Trolard. As these venous structures can be encountered surgically, this study aimed at further elucidating their anatomy, identifying surgical landmarks, and associated quantitation. Thirty-five adult cadavers were dissected of lateral lacunae. Following quantitation of the lacunae, these structures were measured, as were the distances from them to the coronal and sagittal sutures. A mean of 1.9 lacunae were identified on the right sides and 1.4 lacunae on the left sides. Although there tended to be slightly more lacunae on the right sides, this difference did not reach statistical significance (p > 0.05). The average lengths of the lacunae were 3.2 and 2.0 cm for the right and left sides, respectively. The mean widths of these venous lakes were 1.5 cm for the right sides and 0.8 cm for the left sides. Lacunae were variably positioned but tended to cluster near the vertex of the skull. None were identified posterior to the lambdoid sutures, and only 5 were found to lie anterior to the coronal suture, with 4 of these located on right sides (p < 0.05). When lacunae were identified anterior to the coronal suture, they were generally 5-6 cm from this structure. The majority of lacunae could be identified between the coronal and lambdoid sutures and within 3 cm of the midline. Although the situation varies, lateral lacunae are concentrated posterior to the coronal suture and anterior to the lambdoid sutures. They are most often found within 3 cm of the sagittal suture. These previously unreported data could be useful to the neurosurgeon in planning surgical procedures that traverse the calvaria.

Letters to the Editor

Letters to the Editor

The Effect of 0.5% Sodium Tetradecyl Sulfate on a Venous Lake Lesion.

A venous lake lesion is a venous ectasia that occurs on the exposed skin of elderly people. Although a number of therapies such as surgical excision, laser therapy, infrared coagulation, cryotherapy and sclerotherapy have been used to treat venous lakes, there is no guideline for treating this lesion. The purpose of this study was to determine whether 0.5% sodium tetradecyl sulfate (STS) is effective for the treatment of venous lake lesions. Twelve patients with venous lake lesions were enrolled In this study. After proper antiseptic preparation, 0.5% STS was slowly injected into each subject's lesion, and this was followed by immediate compression for 10 minutes. After treatment, all of the patients' lesions cleared completely. The average number of treatments was 2.15±1.28. Two patients experienced mild side effects such as light pain and paresthesia, and these soon disappeared. There were no serious side effects reported during treatment. The mean follow up period was 29.58±13.48 months. We have demonstrated that sclerotherapy with 0.5% STS was quite effective for treating venous lake lesions, and this treatment caused no serious adverse effects.

Glomus Tumor of the Cheek

We are reporting two cases of glomus tumor of the cheek that we had recently encountered during the last six months. English literature is briefly reviewed. CASE REPORTS A 51-year-old male presented with an asymptomatic red right lower cheek lesion that was clinically diagnosed as a “venous lake”. An excisional biopsy was performed and showed a glomus tumor (Figures A1, A2, and A3). Figure 1 Figure A1: Right check glomus tumor in a 51-year-old male Figure 2 Figure A2: Microscopic appearance Figure 3 Figure A3: Higher magnification The second case was that of a 58-year-old female with a left Glomus Tumor of the Cheek 2 of 4 check lesion that was clinically thought to be “epidermal cyst”. An excisional biopsy revealed the typical features of a glomus tumor (Figures B1, B2 and B3). Figure 4 Figure B1: Left check glomus tumor in a 58-year-old female Figure 5 Figure B2: Microscopic appearance Figure 6 Figure B3: Higher magnification Microscopically both tumors showed prominent vascular spaces rimmed by a variable thickness of glomus cells (Figure 2) with dark small uniform nuclei and slightly eosinophilic cytoplasm (Figure 3). There was no mitotic activity or necrosis. COMMENT Glomus tumor is a rare benign painful tumor commonly found in the corium and subcutaneous tissue, mostly in the subungual region of the fingers. It arises from the rests of glomus bodies, which are specialized structures at arteriovenous anastomosis functioning in thermal regulation. Extradigital glomus tumor is a rare entity, especially in the location, such as cheek. In a reported study of 56 extradigital glomus tumors seen in Mayo Clinic over a period of twenty years (1985-2005), the authors found a single case occurring in the cheek [1]. Other reported sites for extradigital glomus tumors include face [2], colon [3], stomach, lung, bone, nervous system, and fallopian tubes [1]. Extradigital glomus tumors can be a diagnostic challenge for the clinicians. The characteristic symptoms of digital glomus tumors, e.g., pain, pinpoint tenderness with blunt palpation, and hypersensitivity to cold, may not be present. Excisional biopsy is usually necessary for the diagnosis as well as the treatment CORRESPONDENCE TO Deba P. Sarma, M.D. Department of Pathology Creighton University Medical School Omaha, NE 68131 debasarma@creighton.edu Glomus Tumor of the Cheek 3 of 4

Histologic study of arteriovenous shunts in the normal dura mater adjacent to the transverse sinus

Background Although AV shunts are known to exist in the normal dura mater, their histologic appearance has not been examined in detail. Arteriovenous shunts in the normal dura mater adjacent to the transverse sinus, the most frequent site of DAVFs, were studied histologically. Methods Normal dura mater adjacent to the transverse sinus was obtained from 8 cadavers. Each specimen was cut into approximately 4- μm-thick serial sections; these were stained by the elastic Masson method and examined under a light microscope. Results Of the 8 specimens, 5 harbored a total of 6 AV shunts; no shunts were found in the other 3 specimens. The shunts, located in the supratentorial (n = 1) and infratentorial dura mater (n = 4) and in the tentorium cerebelli (n = 1), were classified into 2 types. In direct-type shunts, the artery connected directly to the vein; the diameter of these shunts ranged from 40 to 80 μm. In indirect-type shunts, the artery and vein were parallel and were indirectly connected by a shunt vessel, producing an H shape. The diameter of these shunt vessels ranged from 30 to 45 μm. All 6 shunts were connected to veins or the venous lake; none connected directly to the transverse sinus. Conclusions The existence of direct- and indirect-type AV shunts in the normal dura mater was confirmed histologically. Both types exhibited the histologic features of DAVFs, suggesting that AV shunts in the normal dura mater might be involved in the etiology of DAVFs.

Lippenrandangiome

Venous lakes of the lip are a cosmetic problem for many patients due to their exposed location, nodularity, fragility and blue color. We sought an effective and well tolerated therapy method. Over one year, we treated 20 patients with a combination of diode laser (910 nm) and radiofrequency. In all cases, there was complete regression of the venous lake (average: 1.4 treatment sessions). Side effects were transient pain that was assessed as mild by the patients, and transient swelling. Scarring or hypo-/hyperpigmentation did not occur. This combined approach is a recommended option at least equivalent to other therapy methods (argon laser, CO(2) laser, pulsed-dye-laser, and others), or even superior to them due to the low rates of side effects and low number of treatment sessions.

Dermoscopy of Solitary Angiokeratomas

To describe the dermoscopic structures and patterns associated with solitary angiokeratomas and to determine the sensitivity, specificity, positive predictive value, negative predictive value, and reproducibility of these dermoscopic features. Multicenter retrospective study. University hospitals in Spain, Italy, Argentina, New York City, and Austria. There were 256 patients total, and 32 specimens each of solitary angiokeratomas, melanocytic nevi, Spitz-Reed nevi, malignant melanomas, pigmented basal cell carcinomas, dermatofibromas, seborrheic keratoses, and other vascular lesions (19 angiomas, 7 pyogenic granulomas, 3 spider nevi, 2 lymphangiomas, and 1 venous lake) were consecutively collected from the laboratories of 8 hospitals. Diagnoses of all patients' lesions were confirmed histopathologically. Dermoscopic examination. The frequency, sensitivity, specificity, positive predictive value, negative predictive value, intraobserver agreement, and interobserver agreement of the different dermoscopic features associated with solitary angiokeratomas were calculated, and the differences were evaluated using the chi(2) or Fisher exact test. Six dermoscopic structures were evident in at least 50% of the solitary angiokeratomas: dark lacunae (94%), whitish veil (91%), erythema (69%), peripheral erythema (53%), red lacunae (53%), and hemorrhagic crusts (53%). Dark lacunae exhibited a sensitivity of 93.8% and a specificity of 99.1% (P<.001 for both), not being found in malignant melanomas or pigmented basal cell carcinomas. The positive predictive value was 93.8%, and the negative predictive value was 99.1%. The intraobserver agreement was perfect (kappa, 1.00), and the interobserver agreement was excellent (kappa range, 0.83-1.00) (P<.001 for both). Pattern 1, consisting of dark lacunae and whitish veil, exhibited a sensitivity of 84.4% and a specificity of 99.1% and was not found in malignant melanomas or pigmented basal cell carcinomas. The positive predictive value was 93.1%, the negative predictive value was 97.8%, the intraobserver agreement was perfect (kappa, 1.00), and the interobserver agreement was excellent (kappa range, 0.83-1.00) (P<.001 for all). Conclusion Dermoscopy is helpful in improving the diagnostic accuracy of solitary angiokeratomas and allows the observer to differentiate them from other cutaneous tumors such as malignant melanomas and pigmented basal cell carcinomas.

Evaluation of the treatment of venous lakes with the 595-nm pulsed-dye laser: a case series

Venous lakes (VLs) are common benign venous ectasias in the upper dermis. They are treated to improve cosmesis and occasionally to prevent bleeding. Numerous methods have been used, such as cryotherapy, infrared coagulation and various types of lasers. They are variable in their success and all can be complicated by scarring. We report our experiences of using the 595 nm pulsed-dye laser (PDL), which has not been previously described. Eight patients were treated but sufficient resolution was achieved in only three patients. The limited success with this laser could be attributed to insufficient thermal energy being generated to close all the blood vessels permanently. A large prospective study would provide further data regarding the efficacy of the PDL. The use of compression and longer pulse durations may improve the efficacy of the 595 nm PDL to treat VLs.

Injection sclerotherapy of the lower limb: 25 years of experience with 115000 injections

The author began to deal with injection sclerotherapy 25 years ago, which is still being practised by him to this day. Experience is drawn from 115 000 injections given to 4025 limbs of 3107 patients. The mean age is 41.7 years, 80.3% of patients were women. For decades, medicines necessary for sclerotherapy (polidocanol, tetradecylsulphate) have been available in Hungary. At the same time diagnosis and method have developed both abroad and in Hungary. Instead of the previously used standard standing position, the patient is either sitting or lying during the puncture. The diameter of the needle used is smaller than earlier. Previously at the injection the patient was lying and her leg was raised, but now usually she is in the same position as during the puncture. The amount of given medicine at one session was 1 x 0.2 ml, later 4 and 6 x 0.5 ml, but now the allowed maximal dosage is 28 ml 0.5%. Treatments were successful in every case and there were not any serious complications. This method has an outstanding importance in the treatment of intracutaneous venectases and reticular varicosis but side branches and perforators can be cured as well. As is well known, varicosity is a progressive disease and the sclerotherapy can be repeated unrestricted. It is therefore suitable for its treatment in the long run. Strong reactions and complications: The most common strong reactions are fainting, suffusion, phlebitis and pigmentation at the site of the injection. Very rarely blistering, allergic reaction and deep venous thrombosis. The latter is highly focused, therefore the patient's thrombophilic history is revealed. The authors' results and the survey in Hungary showed 1.5% complication in treated patients including one non serious deep venous thrombosis. The recently introduced ultrasound-guided foam sclerotherapy of the leg is suitable for the injection of stem varicosities. Successful treatments were carried out not only in the lower leg but also in upper limb varicosities, vascular malformations, venous lake of the lip and hemorrhoidal nodes. The sclerotherapy and operation rather supplement each other than compete. Sclerotherapy has proved to be suitable for the therapy of lower limb varicosity and some other venous dilatations.

Clearance of Multiple Venous Lakes with an 800-nm Diode Laser: A Novel Approach

Clearance of Multiple Venous Lakes with an 800-nm Diode Laser: A Novel Approach

Long-Pulsed Nd:YAG Laser Treatment of Venous Lakes: Report of a Series of 34 Cases

Some venous lakes do not respond well to traditional vascular lasers. The Nd:YAG laser output at 1,064 nm is less well absorbed by hemoglobin but penetrates more deeply into tissue. This study was undertaken to assess the effectiveness of the long-pulsed Nd:YAG on venous lakes. Thirty-five consecutive adult patients presenting with a venous lake were studied. Four patients had failed to respond to polidocanol 1% sclerotherapy, and 1 patient to pulsed dye laser. Long-pulsed Nd:YAG was administered via a water-cooled tip. Either a 3-mm spot at 250 J/cm(2) and 55 ms or a 5-mm spot at 140 to 180 J/cm(2) was used depending on the size of the lesion. Clinical end points were characterized by hardening of the lesion, central blackening, minimal whitening of the periphery, and in most cases, an audible popping sound. Responses were assessed visually in 50% of cases or by phone contact in the remaining 50% if the lesion had completely disappeared. One patient was lost to follow-up. After a single treatment, 94% cleared completely; incomplete clearance occurred in 6%. There were no reported complications. The long-pulsed Nd:YAG laser is highly effective treatment for venous lakes of the lip and cheeks.

Long-Pulsed Nd:YAG Laser Treatment of Venous Lakes

Long-Pulsed Nd:YAG Laser Treatment of Venous Lakes

Sonographic Diagnosis of Gestational Trophoblastic Disease and Comparison With Retained Products of Conception

Gestational trophoblastic disease (GTD) and retained products of conception (RPC) can be difficult to distinguish sonographically. The aim of this study was to determine whether there were any sonographic criteria that could prospectively distinguish one from the other. Institutional ethics approval was obtained, and acquisition of consent was waived by the Institutional Review Board. A retrospective review of gynecologic oncology and pathology databases identified 17 cases of GTD and 14 cases of RPC. Findings from the pre-evacuation transvaginal sonographic examinations were analyzed. The scans were independently reviewed by 2 senior radiologists with specific expertise in pelvic sonography using several predetermined sonographic features. The reviewers were blinded to the diagnosis. A consensus reading was obtained. The sonographic features that predicted GTD were a myometrial epicenter (P = .0002; odds ratio [OR] = 28), depth of myometrial invasion of more than one third (P = .001; OR = 20), placental venous lakes (P = .04; OR = 9), maximum mass dimensions of more than 3.45 cm (P = .009), and maximum endometrial thickness of less than 12 mm (P = .02). The remaining criteria were not statistically significant and included the characteristics of the mass, ascites, a "snowstorm" appearance, mass vascularity (including resistive index and peak systolic velocity), and the presence of ovarian cysts. There are specific transvaginal sonographic features that can accurately differentiate GTD and RPC.

Calibre persistent labial artery: clinical features and noninvasive radiological diagnosis

Calibre persistent labial artery (CPLA) is defined as a primary arterial branch that penetrates into the submucosal tissue without division or decrease in diameter. It usually presents as an asymptomatic papule on the lower lip and can be easily misdiagnosed as a varix, haemangioma, venous lake, mucocele or fibroma. When it is ulcerated, squamous cell carcinoma is the most usual differential diagnosis. The most frequently used method to confirm the diagnosis of CPLA has been excisional biopsy, which carries the risk of profuse bleeding. Angiography, another invasive method, has also been used. Here, we report a case of a 20-year-old woman with a 5-year history of multiple CPLA lesions involving both upper and lower lips. In this case, the diagnosis was made clinically and confirmed by Doppler ultrasonography, which is a noninvasive and simple diagnostic tool.

Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases

The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diploë (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 +/- 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4-5) and 8 (26.7%) had poor results (GOS 1-3). Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.

Prospective series of infrared coagulation in the treatment of venous lakes of the vermilion lip

Prospective series of infrared coagulation in the treatment of venous lakes of the vermilion lip

Treatment of vascular abnormalities with a long‐pulse diode at 980 nm

Background: Lasers have been used to treat a variety of vascular abnormalities for over 20 years. For minor vascular targets, a small and friendly diode laser with cooling handpiece appears to be a challenger to other systems. Objective: The purpose of this study was to compile treatment data and to examine the effectiveness of a longer pulse duration diode laser in the treatment of vascular pathologies such as facial telangiectasia, venous lakes, spider nevi, blue telangiectasia, leg veins and dermatological treatments. Subjects and methods: Thirty patients were treated with the diode laser with a pulse of 150 ms, energy densities of 300–500 J/cm2 and wavelength at 980 nm. Patients were treated with a surface cooling device. Clinical evaluations were categorized into improvements of 0–25%, 25–50%, 50–75% and greater than 75%.Results: 60% of the patients have up to 50% improvement. The maximum clearance was obtained with only one treatment. However even the cooling system is performed +5°C, pain was relatively high for a majority of patients.Conclusions: The long‐pulse diode laser at 980 nm is effective for treating a wide variety of small vascular abnormalities, for deep and thick vascular lesions and leg veins. The surface cooling device is useful for epidermal protection and pain‐free treatment.

Three-dimensional rotation venography using the digital subtraction angiography unit with a flat-panel detector: usefulness for the transtemporal/transtentorial approaches

We obtained the venograms using the two-dimensional digital subtraction angiography (2D DSA) images and three dimensional rotation venography (3D RV) images and investigated the potential usefulness of the 3D RV compared with venograms of 2D DSA using the newly developed three-dimensional rotation angiography unit with a flat-panel detector (FPD). This study included 26 sides (11 left, 15 right) in 20 cases (4 males and 16 females) who underwent radiographic examination for management of intracranial tumors and vascular diseases between May 2003 and December 2003. Each patient underwent diagnostic angiography performed on a DSA unit with a FPD. In all patients, the 2D DSA images, including anteroposterior view and lateral view of the carotid artery, were obtained in two stereoscopic views. The 3D RV was used to produce volume-rendered images. Two neuroradiologists investigated the venous configuration of 3D RV compared with that of 2D DSA about the relationship of the venous drainage system on the temporal lobe according to Guppy et al.'s classification. Twenty-four sides of the 26 sides enabled the precious visualization on 3D RV images. In investigation of 2D DSA, 9 sides (37.5%) were classified into type A, 13 (54.2%) into type B, two (8.3%) into type C, and no sides into types D, E, and F. In investigation of 3D RV images, 10 sides (41.7%) were classified into type A, 9 (37.5%) into type B, 1 (4.2%) into type C, 2 (8.3%) into type E, and 2 (8.3%) into type F. Seven of 24 sides demonstrated discrepancy in results between 2D DSA and 3D RV. The 3D RV could be performed by setting the adequate delay in between the injection of the contrast material and starting time of third rotation to acquire the opacified images. In Guppy et al.'s classification, the 3D RV images could demonstrate the precious venous drainage including the venous lakes with use of multiple views and variable reconstruction compared with 2D DSA. Our DSA system with FPD could provide good 3D RV images. These images are very useful for the skull-base surgery because we can understand the three-dimensional vascular anatomy preoperatively.