Table of Contents  
IMAGES AND TECHNIQUES
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 67-75

VASCULAR CLINICS: Images & Techniques 2


Date of Web Publication16-Mar-2020

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DOI: 10.4103/0972-0820.280681

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How to cite this article:
. VASCULAR CLINICS: Images & Techniques 2. Indian J Vasc Endovasc Surg 2020;7:67-75

How to cite this URL:
. VASCULAR CLINICS: Images & Techniques 2. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 14];7:67-75. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/67/280681



A new section has been added to IJVES since 2019 October – December issue, which essentially depicts the procedures performed by Vascular Surgeons across the country. This would serve as a pictorial library of multitude of vascular pathologies, simple to complex, common to rare and their therapies. We hope this would create awareness among non-vascular specialists about vascular diseases and the treatment modalities offered by vascular surgeons. This would replace the previous lengthy, text-based CME articles and would be an easier read. It would serve as quick reference to numerous vascular diseases seen by practicing doctors in various specialties across India.

These reports are non-peer reviewed, non-referenced articles. Neither IJVES nor publishers hold copy right to these articles – Editors


  Vascular Malformations Top


Vascular malformations are not uncommon entities, which are not always diagnosed appropriately and treated as per present guidelines. Here we present a few illustrative of these anomalies and their therapies. The following excerpts are reproduced verbatim from excellent article in IJVES by Sumit Kapadia, Vijay Thakore, Hiten Patel .(1) It is recommended that the article should be read in entirety to acquire a comprehensive knowledge about these pathologies. The tables and reference numbers are as cited in their article.

”Congenital vascular malformations are one of the most challenging subgroup of diseases treated by vascular surgeons and interventionalists. Currently, there exists a lot of misunderstandings and controversies in terminology, diagnosis, and management of patients with these problems. This review article helps doctors with a concise and current understanding of classification, clinical features, complications as well as diagnostic and therapeutic guidelines

Vascular anomalies were classified originally by Mulliken and Glowaczki in 1982 based on clinical features and biologic behaviour. However, currently, the International Society for the Study of Vascular Anomalies (ISSVA) classification system is widely accepted and utilized to categorize vascular anomalies into two basic types: (1) vasoproliferative or vascular neoplasms such as hemangioma and (2) developmental vascular abnormalities called congenital vascular malformations (CVMs)(1)

The clinical importance of classification is important to reduce the confusion in treatment principles.



CVMs are a large group which include venous malformation (VM), arterial malformation, capillary malformation (CM), and lymphatic malformation (LM), as well as arteriovenous malformation (AVM) malformations. They remain a difficult diagnostic and therapeutic challenge due to the varied clinical presentations, unpredictable clinical course, inconsistent response to treatment with high recurrence rates, and confusing terminology.(8),(9)

Diagnostic Approach to Vascular Malformations:

A thorough clinical exam is mandatory including documentation of thrill and bruit



and following should be considered and individualized for each patient

  1. Hematologic Evaluation
  2. Ultrasound and color Doppler evaluation
  3. MR Angiography (preferred) and CT Angiography in few selected patients
  4. Digital Subtraction Angiography (DSA) – absolutely needed before intervention in AVMs





  Treatment Top


General principles for congenital vascular malformation

The multidisciplinary team approach is recommended with the aim of proper selection or combination of surgical, nonsurgical, or endovascular treatment methods.(32),(53) Some guiding general principles are as follows:(32)

  1. Not every CVM is amenable to treatment
  2. Not every CVM needs to be treated aggressively
  3. An overzealous approach sometimes does more harm than good (54)
  4. Observation sometimes remains the best approach yet until figuring out the exact nature of the lesion
  5. When the benefit of treatment outweighs the risk of complications and morbidity, less risky treatment options should be first-line therapy
  6. In contrast to the treatment of AVMs, all VM lesions can be treated using a less aggressive approach
  7. It is usually safe to delay treatment until the child reaches to the age of two or more years before beginning diagnostic procedures and treatment (55)
  8. However, for the VM lesion at a life- or limb-threatening anatomic location, an earlier treatment approach is preferred over a more conservative one
  9. In limb- and life-threatening situations, sacrificing limb over life may be necessary
  10. Complicated patients may be referred to an experienced centre in time


Conservative management

Proper skin care, wound dressings, compression bandages, or stockings as well as orthopedic footwear to correct deformities are the foremost means of conservative treatment.(32) Extensive, multifocal, infiltrating, and painful CVMs should be treated with weight-adjusted dose (100 U/kg/d) of LMWH.(40) Certain indications for treatment of CVM are enlisted in [Table 5] and [Table 6].





Modalities of treatment include the following, most of the time in combination:

  1. Sclerotherapy
  2. Endovenous thermal ablation with LASER
  3. Open surgical resection, often combined with other modalities
  4. Embolotherapy to obliterate the nidus and /or endovascular – percutaneous



  Conclusion Top


Vascular anomalies remain one of the most complex and ill-understood diseases treated by a vascular surgeon. A proper knowledge of classification and correct diagnosis helps in deciding and delivering appropriate treatment. Treatment of vascular anomalies is challenging and often involves various therapeutic options. Multidisciplinary approach with full integration of open surgical and endovascular therapy has become the mainstay of treatment in the contemporary management of CVMs.

  1. Kapadia SR, Thakore VM, Patel HM. Vascular malformations: An update on classification, clinical features, and management principles. Indian J Vasc Endovasc Surg 2017;4:152-62



  Vascular Malformations – Images & Techniques Top


1. Drs. Sumit Kapadia, Vijay Thakore, Vadodara





Case 2:





2. Dr. Kiran Dave, Ahmadabad

Venous malformation of the right side of the face, extending in to oral cavity, in a young girl treated with ascarol foam and bleomycin injection directly in to the malformation





3. Dr. P. C. Gupta, Dr. B Pradeep, Dr. Y Vamsi Krishna, Hyderabad

34-year old female patient presented with ulceration over right mid sole and bloody and purulent discharge from it since last 10 years. She gave history of surgery over dorsum of right foot for AVM 11 years back. Pedal pulses were palpable. Loud continuous bruit could be auscultated over the foot. There was a 4cm diameter dirty scab on the mid sole.

Angiography showed right foot AVM with major feeders from anterior and posterior tibial arteries.



She underwent angiography and ultrasound guided percutaneous injection of cyanoacrylate at two points, one fed by ATA and the second by PTA. The femoral vein was compressed for a minute during the injection. Soft bruit was present at the end of the procedure. All toes were pink with normal capillary filling.















4. Dr. Tarun Grover, Dr Virend Sheorain, Gurgaon

31yr Old male, C/o Persistent Lower Abdominal Pain Urgency / Rectal Discomfort. Pulsatile Mass per abdomen



Multiple Percutaneous Accesses obtained using Dyna CT and Duplex guidance , along with Trans-arterial and Transvenous Access





Completion Angiogram Complete exclusion of AVM

5. Dr. Vivekananda, Bengaluru

79 yr / Female with no known medical illnesses, with history of dilated veins left upper limb since birth. Increasing in size for 5 years with several episodes of bleeding, last a week back. Autoamputation of distal phalanx 3rd, 4th and 5th fingers. Increasing dull aching pain left forearm for 4 months. Initial ECHO showed 30% EF, but with no history of any symptoms or cardiac events. Hypertrophy of left forearm with all pulses palpable. Thrill and bruit over the distal forearm and hand.


















 

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