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An institution-wide algorithm for direct-stick embolization of peripheral venous malformations
- Source :
- Journal of Vascular Surgery: Venous and Lymphatic Disorders. 6:351-357
- Publication Year :
- 2018
- Publisher :
- Elsevier BV, 2018.
-
Abstract
- Objective No standardized therapeutic algorithm or embolic agent of choice has yet been identified for management of congenital peripheral venous malformations (VMs). Treatment options and reported outcomes therefore vary widely. Herein, we present an institution-wide algorithm for management of symptomatic congenital peripheral VMs using a single embolotherapeutic modality. Methods During 36 months, patients with symptomatic congenital peripheral VMs underwent contrast-enhanced magnetic resonance imaging. Hematologic monitoring for localized intravascular coagulopathy was performed in all. Perioperative anticoagulation was administered accordingly. When applicable, venous duplex ultrasound was performed to assess for presence and patency of a deep venous system and superficial venous reflux. If superficial venous reflux was identified, radiofrequency ablation was performed per standard protocol before or at the time of initial embolization. Direct-stick embolizations (DSEs) were performed by a single operator using two concentrations (1% and 3%) of sodium tetradecyl sulfate (STS; Sotradecol; AngioDynamics, Latham, NY) without foam preparation. Patients were followed up clinically for resolution of symptoms, coagulopathic monitoring, and development of complications. All data were prospectively maintained and retrospectively reviewed. Results There were 71 DSEs performed in 40 patients (1.8 procedures per patient [range, 1-8]; 12 male patients; mean age, 22 years [range, 2-53 years]). Mean follow-up was 17.1 months (range, 0.8-31.6 months). Presenting symptoms included pain (n = 40 [100%]), swelling (n = 36 [90%]), and cosmetic disfigurement (n = 32 [80%]). Anatomic distribution was upper extremity (n = 16 [23%]), lower extremity (n = 37 [52%]), head and neck (n = 7 [10%]), trunk (n = 10 [14%]), and visceral (n = 1 [1%]). There were 33 sporadic cases, 4 (10%) Klippel-Trenaunay syndrome cases, 2 (5%) blue rubber bleb nevus syndrome cases, and 1 (2.5%) CLOVES (congenital lipomatous overgrowth, vascular malformations, epidermal nevus, and skeletal deformities) syndrome case. Four patients presented with localized intravascular coagulopathy, two of whom required perioperative enoxaparin. Twenty-six patients (65%) required a single DSE session with complete symptom relief. Fourteen patients (35%) required repeated DSE. Two patients (5%) required adjunctive surgical excision. There was one postoperative death (1.4%) secondary to massive pulmonary embolism. Complications were otherwise limited to skin necrosis (n = 2 [3%]). Mean volume of sclerosant per session was 7 mL of 1% STS (range, 3-14 mL), and 15 mL of 3% STS (range, 3-42.5 mL). Conclusions In the absence of allergic reactions, most congenital peripheral VMs can be safely embolized with liquid STS, thereby avoiding the well-documented toxicity of ethanol. Venous thromboembolism remains a major source of morbidity and mortality in this population of patients despite close hematologic scrutiny. Prospective randomized trials are needed for embolotherapeutic standardization.
- Subjects :
- Adult
Male
Adolescent
Vascular Malformations
medicine.medical_treatment
Population
030204 cardiovascular system & hematology
Risk Assessment
030218 nuclear medicine & medical imaging
Sodium Tetradecyl Sulfate
Young Adult
03 medical and health sciences
0302 clinical medicine
Coagulopathy
Humans
Medicine
Embolization
Child
education
Retrospective Studies
Peripheral Vascular Diseases
education.field_of_study
business.industry
Anticoagulants
Retrospective cohort study
Perioperative
Heparin, Low-Molecular-Weight
Middle Aged
medicine.disease
Embolization, Therapeutic
Magnetic Resonance Imaging
Sclerosing Solutions
Sodium tetradecyl sulfate
Blue rubber bleb nevus syndrome
Pulmonary embolism
Child, Preschool
Female
Surgery
Cardiology and Cardiovascular Medicine
business
Algorithm
Algorithms
medicine.drug
Subjects
Details
- ISSN :
- 2213333X
- Volume :
- 6
- Database :
- OpenAIRE
- Journal :
- Journal of Vascular Surgery: Venous and Lymphatic Disorders
- Accession number :
- edsair.doi.dedup.....f8ac740e169ce745bbe4807313ff2338