1. 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

2. 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.

3. Learning objectives
Review prevalence and etiology of venous malformations
Discuss appropriate workup and imaging
Review indications and basic techniques for treatment

4. 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)

5. 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

6. Venous Malformations Abnormal collections of veins
Variable luminal diameter and wall thickness
Not “normal” veins
No elastic intima
Paucity or lack of smooth muscle

7. Venous Malformations Can occur anywhere
Deep, superficial, diffuse, localized, multiple
Associated with syndromes (Klippel- Trenaunay, Parkes-Weber, Blue rubber bleb)

9. Venous Malformations Histologically No elastic intima
paucity/absence of smooth muscle

10. Clinical Usually present with pain or swelling
Soft, compressible, variably blue tinged
Trans-spatial/compartmental

12. Clinical Dependent venous engorgement
Impinge on nerve/fascial tissues = pain
Bleeding/Hemarthrosis
Localized stasis in lesion = thrombosis/thrombophlebitis = pain (can form phleboliths)

13. Imaging US First modality usually employed Heterogenous but hypoechoic
Tubular anechoic structures/channels not always appreciated

14. Imaging Doppler Monophasic flow most common
Biphasic or high velocity arterial flow are NOT typical (think AVM or AVF)

15. Imaging

16. Imaging MRI Define relationships to deeper critical structures
3D reconstructions
Follow response to therapy
Consider time resolved MRA techniques

18. Imaging
Radiographs occasionally to evaluate for bone overgrowth or remodeling (phleboliths seen about 16% of lesions)

20. Imaging Nuclear medicine not contemporarily used
Low spatial resolution
Lack of specificity

21. Treatment Decisions Conservative Compression, ASA Intervention
Sclerotherapy/embolization

22. Treatment decisions Bleeding
Lesions located at life or limb threatening region
Disabling pain
Limb length discrepancy/vascular bone syndrome

23. 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?

24. Sclerotherapy
Legiehn GM, et al Classification, diagnosis, and interventional radiologic management of vascular malformations. Orthop Clin North America 2006;37:435-74

25. Sclerotherapy Choice of sclerosant STS EtOH Polidocanol n-CBA glue
Dwell time

26. Sclerotherapy US guided needle placement
Contrast injection to see confines of lesion and runoff
Many times more than one needle

27. Sclerotherapy Control of sclerosant Compression of runoff if possible
Slow injection
Vent needle for larger lesions
Not too much compression or extrav will occur. Vent needle path of least resistance some distance away from injecting needle

29. Sclerotherapy

30. Future directions??
Society for Interventional Radiology Annual Meeting March 2016

34. Summary Clinical/Imaging findings Treatment options Conservative/none
Compression
Sclerotherapy