Xiaojie Hu

Sclerotherapy after embolization of draining vein: A safe treatment method for venous malformations

BACKGROUND Treatment of congenital venous malformations poses a major clinical challenge. Great successes have been achieved with ethanol sclerotherapy in most lesions; however, severe complications are more likely to occur when more ethanol is used. OBJECTIVES This study evaluated the safety and efficacy of a new sclerotherapy treatment that uses absolute alcohol and bleomycin A5. We evaluated our experience to present a safe treatment method for venous malformations. METHODS The study population comprised 201 patients. Before treatment, lesions were categorized according to magnetic resonance imaging features: 120 patients had limited venous malformations, and 81 had infiltrating venous malformations. Percutaneous sclerotherapy was performed by direct injection of absolute alcohol and bleomycin A5 under fluoroscopy. The mean dose of the two medicines was 3.4 mL and 3.7 mg, respectively. We investigated 592 sclerotherapy sessions. A retrospective study was performed of medical records and color photographs and magnetic resonance imaging before and after treatment The mean follow-up was 29 months (range, 12-65 months). RESULTS After embolization of the drainage vein with ethanol, a subsequent sclerosis therapy with bleomycin A5 was judged beneficial in 196 of 201 patients. Among the 196 responders, 56 showed disappearance of their chief symptoms, 42 showed improvement to nearly normal, and 62 showed marked improvement. The best response to our treatment was among the patients with limited venous malformations, with 114 (95%) showing at least marked improvement. Complications were tissue necrosis in 6 sessions, peripheral nerve palsy in 5, pigmentation in 10, blistering in 5, and 87 sessions resulted in transient side effects related to bleomycin A5, such as fever and gastrointestinal irritation. All were self-limited. No major complications such as cardiopulmonary collapse or pulmonary fibrosis were observed. CONCLUSION Percutaneous sclerotherapy of venous malformations using absolute ethanol and bleomycin A5 is safe and effective. The simplicity, speed, and safety of sclerotherapy, combined with the quality and stability of the outcome achieved with our novel procedure, may make the technique the choice for treatment of venous malformations.

Outcomes and Complications of Sclerotherapy for Venous Malformations

Objective: To determine the efficacy of sclerotherapy for venous malformations (VMs). Methods: PubMed was used to search the medical literatures for publication on the combined topics of “VMs and sclerotherapy.” The final evaluation of the venous lesions was based on both objective parameters and subjective parameters. Complications were also recorded. Results: A total of 35 studies published between 1986 and 2011 matched the selection criteria and were included. Ethanol, polidocanol, ethanolamine oleate, and sodium tetradecyl sulfate (STS) are the 4 mainstream sclerosants. The total efficiency of these 4 sclerosants all exceeded 90% except STS. Skin damage (10.0%) was the most common minor complication. Other complications included renal damage (3.9%), nerve damage (1.85%), muscle damage (0.66%), pulmonary embolism (0.25%), cardiovascular collapse (0.08%), and others. Conclusions: Sclerotherapy is effective for VMs. However, there is limited evidence from randomized clinical trials to support the use of any kinds of sclerosants.

A prospective self-controlled phase II study of imiquimod 5% cream in the treatment of infantile hemangioma.

Abstract:  Imiquimod has been reported to be efficacious in the topical treatment of uncomplicated infantile hemangiomas (IH). However, due to the natural tendency of IH to involute spontaneously, prior uncontrolled efficacy and safety studies have been called into question. We conducted a prospective self‐controlled phase II study of imiquimod initially applied to uncomplicated, proliferative superficial or mixed IHs treating half of each IH once every other night for 16 weeks, leaving the other half untreated. After 16 weeks, an independent dermatologist evaluated the color, area, and volume of each half of the hemangioma. Of the 44 patients treated, the total effective rate was 80% (n = 35), with an overall resolution rated as excellent or good rate in 39% of lesions (n = 17/44). The relapse rate was 2% (n = 1). Side effects were noted in 61% (n = 27) including erythema or/and edema (n = 16%, 7), local itching (n = 7%, 3), peeling (n = 7%, 3), erosion (n = 5%, 2), crusting (n = 55%, 24), ulceration (n = 9%, 4), and scarring (n = 5%, 2). Some patients had two or more side effects. Most were judged to be mild to moderate and did not result in treatment being interrupted. Crusting or ulceration was noted to cause post‐treatment skin reactions, such as texture change, whereas cases without crusting involuted to almost normal skin. No local infection or systemic reaction was observed. The difference in effective rate and side effect incidence between superficial and mixed IH was not statistically significant. Imiquimod 5% cream can be an effective and safe treatment option for superficial mixed IH in which the superficial component predominates. The recurrence rate is low, but local reactions including crusting can develop and result in post‐treatment skin changes.

Fractional carbon dioxide laser-assisted drug delivery of topical timolol solution for the treatment of deep infantile hemangioma: a pilot study.

Infantile hemangiomas (IHs) are benign vascular tumors of infancy. Topical timolol has recently been reported to be an effective treatment for superficial IHs, although it failed to have an effect on deep IHs. This prospective study was aimed at evaluating the feasibility of ablative fractional laser–assisted drug delivery for enhancing topical timolol permeation into deep IHs. Nine patients ages 1 to 6 months with deep IHs were enrolled. A fractional carbon dioxide (CO2) laser system was applied to the skin surface of deep IHs using the DeepFx mode (25–30 mJ/pulse, 5% density, single pulse) at 1‐week intervals. Topical timolol maleate 0.5% ophthalmic solution was applied under occlusion for 30 minutes four to five times per day for an average treatment duration of 14.2 weeks. Clinical improvement was evaluated according to a global score and the Hemangioma Activity Score (HAS). Four patients (44.4%) demonstrated excellent regression, four (44.4%) showed good response, and one (11.1%) experienced moderate regression. The HAS declined from 4.1 ± 0.7 at baseline to 1.7 ± 0.7 at 1 week (p < 0.001) and 1.4 ± 0.7 at 3 months (p = 0.03) after the last treatment procedure. Plasma timolol concentration was not detected in any of the patients after the first administration of topical timolol. No systemic complication or skin side effects were observed in any of the patients. Ablative fractional laser–assisted transdermal delivery of topical timolol is a safe and effective method for the treatment of deep IHs.

Nodules Arising Within Port-wine Stains: A Clinicopathologic Study of 31 Cases

Nodules are seen in approximately 10%-30% patients within port-wine stains (PWS) and usually regarded as vascular “tumor.” However, nodules arising within PWS have not been systematically examined and the precise pathologic characteristics of them are unknown. The aim of this study is to evaluate the clinicopathologic and immunohistochemical features of blood vessels of nodules in 31 cases. A total of 31 biopsy specimens (excision) were obtained from the representative areas of lesion of each patient with nodules. Clinical features of all patients were recorded. Hematoxylin and eosin staining, immunohistochemical staining, and Weigert elastic stain were performed to investigate the histopathologic features of nodules. In a total of 31 subjects, there are 16 patients whose nodules occurred in the area innervated by the second branch of the trigeminal nerve (51.6%), 4 in the first branch (12.9%), 6 in the third branch (19.4%), 2 in both the first, and the second branch (6.5%). Based upon specular microscopic findings, 14 biopsy specimens were designated as pyogenic granuloma (PG) (45.1%), 10 as arteriovenous malformation (AVM) (32.3%), 5 as both (16.1%), and 2 cases as cavernous-like vascular ectasia (6.5%). Moreover, both AVM and PG were prone to occurring in the area innervated by the second branch of the trigeminal nerve. In summary, we believed that both AVM and PG are not rare histologic changes in PWS. Moreover, histologic findings suggest that the major portion of nodules arising within PWS can be categorized into AVM, PG, and AVH associated with PG.

Auricular Arteriovenous Malformations: Potential Success of Superselective Ethanol Embolotherapy

PURPOSE To assess retrospectively the effectiveness and safety of superselective ethanol embolotherapy for auricular arteriovenous malformations (AVMs). MATERIALS AND METHODS Ethanol embolizations were performed under fluoroscopy by direct puncture techniques in eight patients (five male) with auricular AVMs from June 2006 to April 2008. The mean age of the patients was 31.5 years (age range, 10-59 y). Clinical follow-up (range, 5-27 months; mean, 12.6 months) and digital subtraction angiography follow-up (range, 4-25 months; mean, 8.0 months) were performed in all patients. Therapeutic outcomes were established by evaluating the outcome of symptoms and aesthetic appearance, as well as the degree of devascularization at follow-up angiography. RESULTS Fifteen embolotherapy procedures were performed in eight patients. Six patients (75.0%) experienced complete resolution of abnormal angioarchitecture and were rated as cured at follow-up angiography. Complete control of bleeding, ulceration, and pruritus was achieved in all five patients with these symptoms (100%). In terms of aesthetic results, five patients (62.5%) showed complete resolution of the masses and were rated as cured. One patient (12.5%) experienced superficial skin necrosis that healed spontaneously after 4 weeks, without ear defect. Even though all the patients experienced blistering immediately after treatment, the complications were self-limited and minor. There were no major complications. CONCLUSIONS In a limited series, superselective ethanol embolotherapy was effective and safe in the treatment of auricular AVMs.

Craniofacial Venous Malformations: Magnetic Resonance Imaging Features That Predict Treatment Outcome

PURPOSE Craniofacial venous malformations (VMs) are challenging lesions. Treatment is not routinely indicated unless the benefit and loss have been weighed properly. Therefore it is crucial to predict clinical outcome before treatment. This study was performed to retrospectively determine whether pretreatment magnetic resonance imaging (MRI) findings are predictive of outcome in patients who undergo sclerotherapy for craniofacial VMs. PATIENTS AND METHODS MRI findings and clinical results of percutaneous sclerotherapy with ethanol and bleomycin A(5) in 69 patients with craniofacial VMs were retrospectively reviewed. Lesions were categorized with MRI based on margins; 51 were limited VMs, and 18 were infiltrating VMs. We performed t test analysis to assess the difference in the number of sclerotherapy sessions between the 2 groups. The Kruskal-Wallis test was used to evaluate differences in symptom improvement and satisfaction level between the groups. The difference in complication rates was assessed by chi(2) analysis. RESULTS The better response to treatment was among the patients with limited VMs. The number of sclerotherapy sessions was 1.9 +/- 1.2 for limited VMs and 3.6 +/- 1.5 for infiltrating VMs, with a significant difference between the groups (P = .0001). The patients with limited VMs were significantly more likely to have better symptom improvement (P = .0001) and a higher satisfaction level (P = .0001). The complication rates of the limited and infiltrating VMs were 18.2% (18/99) and 32.8% (21/64), respectively. A significant difference was found between the groups (P = .033). CONCLUSIONS The feature of lesion margin on MRI before sclerotherapy is an important predictor of treatment outcome for craniofacial VMs.

Treatment of Venous Infraorbital Dark Circles Using a Long-Pulsed 1,064-nm Neodymium-Doped Yttrium Aluminum Garnet Laser

Background Infraorbital dark circles are a common cosmetic problem with multiple causative factors and few studies into the different treatment options. Objective To assess the effectiveness and safety of long‐pulsed 1,064‐nm neodymium‐doped yttrium aluminum garnet (Nd:YAG) laser therapy for infraorbital dark circles caused by visible prominent veins. Participants and Methods Twenty‐six patients with venous infraorbital dark circles were treated with a Nd:YAG laser (fluence, 130–140 J/cm2; spot size, 6 mm) in double‐pulse mode (pulse width, 6–10 ms; interpulse interval, 20 ms). Patients were examined 12 months after the final treatment. Results were ranked in five categories based on percentage clearance (5 = 100%, 4 = 75–99%, 3 = 50–74%, 2 = 25–49%, 1 ≤ 25% clearance). Patient satisfaction was ranked on a scale of 1 to 3 (1 = minimal improvement; 3 = completely satisfied), and pain was ranked on a scale of 1 to 10 (1 = mild pain; 10 = severe pain). Results Twenty‐six patients completed the study. Objective improvement scores were 5 in all patients, and all patient satisfaction scores were 3. All patients tolerated the moderate pain (mean score 3.6). Transient erythema was observed in all patients. Conclusion Long‐pulsed 1,064‐nm Nd:YAG‐laser treatment appears effective and safe for the treatment of venous infraorbital dark circles and selectively removes visible prominent veins.

Retrospective analysis of facial paralysis caused by ethanol sclerotherapy for facial venous malformation

Absolute ethanol sclerotherapy provides a reliable treatment for facial venous malformation, although facial nerve injury may occur after sclerotherapy. This study is a retrospective review of facial nerve dysfunction after sclerotherapy.

Treating Protruding Infantile Hemangiomas with Topical Imiquimod 5% Cream Caused Severe Local Reactions and Disfiguring Scars

Infantile hemangiomas (IHs) are the most common tumors of infancy. Imiquimod, an immune‐response modifier, has been proven effective and safe in the treatment of superficial and mixed hemangiomas, but severe local reactions caused by imiquimod have been reported sporadically. To evaluate the safety of imiquimod 5% cream and the sequelae of severe local inflammatory reactions in the treatment of superficial IHs we performed a retrospective chart review of all children with superficial IHs who received topical imiquimod treatment in the Department of Plastic and Reconstructive Surgery of Shanghai 9th Peoples Hospital from March 2010 through February 2012 and selected those who had severe local reactions to topical imiquimod for further description. Nine of 224 (4.0%) children with superficial IHs who received imiquimod 5% cream treatment had severe local reactions. All four patients who had follow‐up for longer than 1 year had permanent disfiguring depigmented scars after intensive inflammatory reactions. Seven of the severe reactions happened on protruding IHs and four involved the skin folds and joints, suggesting that imiquimod 5% cream should probably be avoided in IHs with either this morphology or these sites.