Elsevier

Clinical Radiology

Volume 69, Issue 9, September 2014, Pages 931-938
Clinical Radiology

Percutaneous sclerotherapy of foot venous malformations: Evaluation of clinical response

https://doi.org/10.1016/j.crad.2014.04.014Get rights and content

Highlights

  • Treatment of foot venous malformations is a challenge due to their diffuse nature.

  • Percutaneous sclerotherapy is an effective treatment option.

  • Patients reported decrease in swelling and pain, and improvement of foot function.

  • Self limited post-procedural skin complications occur after 21% of the procedures.

  • A shorter lesion to skin surface distance was related to higher complications.

Aim

To evaluate a single institutional experience with percutaneous sclerotherapy of venous malformations (VM) of the foot.

Materials and methods

Sixteen patients (mean age 14.6 years; range 6–27.3 years), who underwent 34 sclerotherapy procedures were retrospectively analysed. Technical success, Puig classification, VM size reduction, and the complication rate were evaluated. In procedures in which C-arm computed tomography (CT) was performed, the VM-to-skin surface distance was measured. Additionally, an e-mail-based questionnaire to evaluate the response to sclerotherapy was answered by the patients.

Results

Technical success was 97%. The mean number of procedures per patient was 2.1 (range 1–5). In all procedures, sodium tetradecyl sulphate foam was used. Appropriate follow-up was available for 29/33 procedures (88%). Post-procedural complications occurred after 6/29 procedures (21%), all of which were self-limited skin complications. C-arm CT was performed in 19/33 procedures (58%). The lesion-to-skin surface distance was significantly shorter in patients with skin post-procedural complications (p < 0.001). The e-mail-based questionnaire was completed by 13/16 patients (81%). Decrease in swelling, improvement of foot function and a significant decrease in pain (p = 0.003) was reported. No patient reported dis-improvement after sclerotherapy.

Conclusion

Percutaneous sclerotherapy is an effective option for treating foot VMs. Skin complication rates are higher with shorter VM-to-skin surface distance.

Introduction

Congenital vascular malformations are classified according to the modified Hamburg Classification,1, 2, 3 which subdivides congenital vascular malformations into arterial, arteriovenous, venous, capillary, lymphatic, and combined vascular malformations.1, 3 This classification is based on the work performed by Mulliken and Glowacki, which subdivided congenital vascular malformations into two broad categories, haemangiomas and vascular malformations, according to biological and histopathological differences.4, 5 It is important to differentiate congenital vascular malformations from infantile haemangiomas. Whereas vascular malformations grow proportionately with age, haemangiomas are vascular tumours with an early proliferative phase and later an involutive phase.2, 4, 6, 7

Venous malformations (VM) are low-flow lesions composed of multiple diffuse abnormal veins of different luminal size and wall thickness.5 VMs are the most common form of congenital vascular malformations accounting for a half to two-thirds of all congenital vascular malformations.3, 8 The treatment of VM in the foot is a challenge due to the diffuse nature, encasement of multiple neuromuscular and articular structures, and restricted blood flow related to the terminal arterial flow and high venous pressure in vertical position. Swelling may cause compartment syndrome with serious consequences.

The cosmetic appearance of VMs and associated symptoms, which include pain, swelling, reduced function, ulceration, and, although rare in small distal VMs, the increased risk for thromboembolic events, influence the decision to treat VMs.6, 9 Therapeutic options most commonly used include conservative compression bandage, excisional surgery, and sclerotherapy.1, 10, 11, 12 Less commonly used modalities include electrocoagulation, cryotherapy, and laser.13 Sclerotherapy using polidocanol, ethanol, ethanolamine oleate, sodium tetradecyl-sulphate (STS), ethibloc, and OK-43210, 11, 13 had been suggested as first-line treatments for VMs.10, 13 Surgery, however, is associated with higher rates of complications including massive bleeding, nerve damage, alteration in the motor function, and poor cosmetic outcome.10 Both techniques have been associated with high recurrence rates, with a 35% recurrence rate reported following sclerotherapy.9, 14 However, repeat sclerotherapy treatment is less invasive.13, 14

The purpose of the present study is to evaluate a single institutional experience with percutaneous sclerotherapy for the treatment of foot VMs. To the authors' knowledge, this is the first dedicated published series of sclerotherapy for foot VMs.

Section snippets

Data collection

This retrospective study was approved by the Institutional Review Board (IRB) and was performed in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Patients who underwent sclerotherapy for foot VMs were identified by performing a search of the radiology database for the time period between January 2007 and September 2012. Relevant clinical and radiology records were reviewed.

Patient population

Sixteen patients, 10 female and six male, who underwent 34 sclerotherapy procedures were

Technique

Technical success was 97% (33/34 procedures). In one procedure, no sclerosing agent was injected due to the presence of deep venous connections. The mean number of procedures per patient was 2.1. The number of procedures per patient is shown in Table 2. The median STS volume used in each procedure was 10 ml (range 1–20 ml).

For all procedures, the median fluoroscopy time was 5.3 min (range 2–10.3 min). For procedures in which C-arm CT was not performed, the median dose–area product was 48.1 μGy/m

Discussion

The literature reports positive outcomes using sclerotherapy for treating VMs.9, 10, 15, 16, 17, 18, 19 The aim of the present study was to describe a single institutional experience with performing percutaneous sclerotherapy for foot VMs in children and young adults. Additionally, the relation between a shorter lesion-to-skin surface distance and a higher skin complication rate was evaluated.

In the Children's Hospital of Philadelphia, the use of C-arm CT is standard of care. The rationale for

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