Paediatric Venous Malformation: Treatment with Endovenous Laser and Foam Sclerotherapy
Article Outline
Vascular malformations can cause significant symptoms in young patients. Current treatment options, including injection sclerotherapy and surgery, are associated with significant morbidity. We report a case in which a symptomatic paediatric venous malformation was successfully treated using a combination of ultrasound-guided endovenous laser therapy and foam sclerotherapy.
Keywords: Venous malformation, Endovenous laser, Foam sclerotherapy
Introduction
Vascular malformations can be challenging to treat and may cause significant symptoms of pain and bleeding. Current management options include sclerotherapy, pulse dye laser therapy or surgical excision, with the emphasis on palliation of symptoms rather than lesion eradication.1 Although these treatments may be effective, they are limited by risks of skin necrosis, scarring, deformity and significant haemorrhage. We report a new technique, in which ultra-sound guided endovenous laser therapy was used in combination with foam sclerotherapy to successfully treat a symptomatic paediatric venous malformation of the lower extremity.
Report
A 6-year-old girl presented with a large venous malformation of the left thigh, associated with significant symptoms of profuse bleeding, despite repeated foam sclerotherapy and cutaneous laser treatments over five years.
On examination, there was an extensive vascular lesion on the lateral aspect of the left thigh, with atrophy of the dermis and subcutaneous tissues and prominent haemangioma (Fig. 1). There was no enlargement of the limb. A duplex scan showed a competent deep venous system, a hypoplastic long saphenous vein with a persistent varicose marginal vein running laterally through the lesion, filled by seven incompetent thigh perforators (3–7
mm). The arterial system was normal.
Fig. 1
Extensive venous malformation on lateral thigh.
Under general anaesthesia, the persistent marginal vein was cannulated percutaneously under ultra-sound guidance and an 810nm diode laser fibre (Varilase, Vascular Solutions, Minisota, USA) inserted using the Seldinger technique. Laser therapy (5W at 40J/s) was performed after tumescent anaesthesia (Fig. 2). Foam (2ml 1% Fibrovein, STD Pharmaceuticals) was injected into the proximal and distal vein segments under ultra-sound guidance. Compression bandaging was immediately applied for 24 hours, followed by a fitted compression stocking. At follow-up at 3 months, the patient's symptoms of bleeding had completely resolved. Duplex venous imaging confirmed that six of the seven incompetent thigh perforators had thrombosed, in addition to the persistent marginal vein.
Fig. 2
Insertion of laser into venous malformation.
Discussion
Current treatments for vascular malformations, including sclerotherapy and surgery, are associated with significant morbidity. Although options of cutaneous laser and sclerotherapy were available for treatment of the extensive cutaneous haemangioma in this case, repeated attempts at sclerotherapy had failed to treat the underlying persistent marginal vein and symptom control was inadequate.
Surgical stripping of the persistent marginal vein with perforator ligation was an alternative management option. However, because of the extensive cutaneous component overlying the marginal vein and multiple perforators, the risks of bleeding and poor healing following surgery were thought to be high and endovenous laser ablation was therefore considered as an alternative approach.
Although MRI is particularly useful in determining the anatomical extent of vascular malformations, Duplex imaging was our investigation of choice in determining suitability of this case for endovenous laser therapy. Although the deep venous system was normal in this case, persistent marginal veins commonly occur with a hypoplastic deep system and the marginal vein may provide an essential collateral venous drainage pathway. Duplex was also used to assess the degree of tortuosity of the marginal vein. The main thigh segment was straight and therefore suitable for advancement of the laser sheath. Proximal and distal segments were tortuous, which was why foam sclerotherapy was used as an additional treatment for these segments.
Endovenous laser ablation has recently been introduced as a minimally invasive alternative to stripping of the long saphenous vein in varicose vein surgery. The risk of serious complications is low, with no skin burns, paraesthesias or deep vein thrombosis in 499 limbs treated with endovenous laser in a recent large series.2 Although the use of endovenous laser in paediatric malformations has also been reported as safe and effective in a small group of patients,3 this is the first time endovenous laser has been reported in the management of a paediatric venous malformation of the lower extremity. The risks of skin burn may be higher in children and should be minimised by the careful use of tumescent anaesthesia. Foam sclerotherapy also appears to be a safe and effective option in the management of venous angiomata.4
By using a combination of endovenous laser therapy and foam sclerotherapy, we have effectively controlled bleeding symptoms in an extensive venous malformation by thrombosing a persistent marginal vein and obliteratingmajor perforators. Endovenous laser therapy should be considered as a treatment option for patients presenting with venous malformations of the extremity, possibly in combination with foam sclerotherapy.
References
- . Management of hemangiomas and pediatric vascular malformations. J Craniofac Surg. 2006;17(4):783–789
- . Laser treatment of vascular birthmarks. J Craniofac Surg. 2006;17(4):720–723
- . Ultrasound-guided endovenous diode laser in the treatment of congenital venous malformations: preliminary experience. J Vasc Interv Radiol. 2005;16(6):879–884
- . Venous angiomata: treatment with sclerosant foam. Ann Vasc Surg. 2005;19(4):457–464
PII: S1533-3167(07)00016-7
doi:10.1016/j.ejvsextra.2007.03.004
© 2007 Elsevier Ltd. All rights reserved.
Refers to article:
- Paediatric Venous Malformation: Treatment with Endovenous Laser and Foam Sclerotherapy , 14 May 2007
