Transcript 1630_Rivard_PL54F6x

Evaluation and treatment of Vascular Malformations
Douglas C. Rivard, DO
Chairman-Department of Radiology
Children's Mercy Hospital Kansas City, Missouri
Associate Professor, University of Missouri-Kansas City
Adjunct Assistant Professor-Kansas University School of Medicine
Disclosures
I do not have a financial interest or other relationship with a commercial
organization that may have an interest in the content of the educational activity.
Learning objectives
1. Review prevalence and etiology of venous
malformations
2. Discuss appropriate workup and imaging
3. Review indications and basic techniques for
treatment
Venous Malformations
• Historically many misnomers—hemangioma,
birthmark, etc
• Occur in about 1:10,000 births
• Current classification schemes dating back to early
1980’s (ISSVA, Hamburg)
Venous Malformations
Almost 50% of referrals to vascular anomalies centers
Studies show…
• 70% of patients given the wrong initial dx
• 20% patients receive improper initial therapy
Hassanein AH, et al. Evaluation of terminology for vascular anomalies in current literature. Plast Reconstr Surg 2011;127(1):347-51
Venous Malformations
• Abnormal collections of veins
• Variable luminal diameter and wall thickness
• Not “normal” veins
• No elastic intima
• Paucity or lack of smooth muscle
Venous Malformations
• Can occur anywhere
• Deep, superficial, diffuse, localized, multiple
• Associated with syndromes (KlippelTrenaunay, Parkes-Weber, Blue rubber bleb)
Venous Malformations
• Histologically
• No elastic intima
• paucity/absence of smooth muscle
Clinical
• Usually present with pain or swelling
• Soft, compressible, variably blue tinged
• Trans-spatial/compartmental
Clinical
• Dependent venous engorgement
• Impinge on nerve/fascial tissues = pain
• Bleeding/Hemarthrosis
• Localized stasis in lesion = thrombosis/thrombophlebitis = pain (can form
phleboliths)
Imaging
• US
• First modality usually employed
• Heterogenous but hypoechoic
• Tubular anechoic structures/channels not always
appreciated
Imaging
• Doppler
• Monophasic flow most common
• Biphasic or high velocity arterial flow are NOT
typical (think AVM or AVF)
Imaging
Imaging
• MRI
• Define relationships to deeper critical structures
• 3D reconstructions
• Follow response to therapy
• Consider time resolved MRA techniques
Imaging
• Radiographs occasionally to evaluate for bone
overgrowth or remodeling (phleboliths seen
about 16% of lesions)
Imaging
• Nuclear medicine not contemporarily used
• Low spatial resolution
• Lack of specificity
Treatment Decisions
• Conservative
• Compression, ASA
• Intervention
• Sclerotherapy/embolization
Treatment decisions
• Bleeding
• Lesions located at life or limb threatening region
• Disabling pain
• Limb length discrepancy/vascular bone syndrome
Pre-treatment
• Coag panel—make sure no consumptive coag issues
• Define expectations--not a cure, multiple sessions is
the norm
• Back up from surgical/plastics/derm colleagues
• Nerve block?
Sclerotherapy
Legiehn GM, et al Classification, diagnosis, and interventional radiologic management of vascular malformations. Orthop Clin North America 2006;37:435-74
Sclerotherapy
• Choice of sclerosant
• STS
• EtOH
• Polidocanol
• n-CBA glue
• Dwell time
Sclerotherapy
• US guided needle placement
• Contrast injection to see confines of lesion and
runoff
• Many times more than one needle
Sclerotherapy
• Control of sclerosant
• Compression of runoff if possible
• Slow injection
• Vent needle for larger lesions
Sclerotherapy
Future directions??
Society for Interventional Radiology Annual Meeting March 2016
Summary
• Clinical/Imaging findings
• Treatment options
• Conservative/none
• Compression
• Sclerotherapy
[email protected]