Venous Malformations Treatment & Management

Updated: Jun 13, 2019
  • Author: Silvio Podda, MD; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS  more...
  • Print
Treatment

Medical Therapy

Sclerotherapy is the primary form of nonsurgical intervention for venous malformations. [3, 4] Larger lesions usually are treated with 95% ethanol, while cutaneous and smaller lesions are treated with sodium tetradecyl sulfate (1%). Sclerotherapy is often performed by an interventional radiologist under general anesthesia. Multiple sclerotherapeutic sessions often are needed. Venous malformations have a propensity for recanalization and recurrence.

An alternative to standard sclerotherapy using sclerosant foam has been described. [6]  For example, a retrospective study by Park et al found sclerotherapy with sodium tetradecyl sulfate foam to be effective against venous malformations, reducing both pain and malformation size. According to the study, which involved 86 patients (91 venous malformations), positive responses with regard to pain and mass reduction were 49.5% and 52.7%, respectively. [19]

In a retrospective analysis of facial paralysis caused by ethanol sclerotherapy, Hu et al concuded that the zygomatic and temporal branches of the facial nerve were the most vulnerable to injury after ethanol sclerotherapy and suggested surgeons to pay close attention when performing ethanol sclerotherapy in those areas. [20]

Compression garments are a mainstay of treatment for extremity venous malformations, particularly the lower extremity. Venous malformations of the GI tract also have been managed by sclerotherapy or endoscopic banding.

Laser therapy has shown promise in selected situations. Argon and yttrium-aluminum-garnet (YAG) lasers have been used to treat intraoral lesions. [21] This approach seems more appropriate for smaller lesions. [22]

Next:

Surgical Therapy

Surgery is indicated in isolated, symptomatic venous malformations or following sclerotherapy to improve form or function. Surgical results are a function of the size and location of the malformation. Recurrence following surgery is more common with diffuse malformations and when excision is incomplete. [17, 23] In general, surgery or sclerotherapy is more successful when dealing with pure venous malformations than when dealing with combined malformations. [22]

A study by Kang et al involving 109 patients with slow-flow vascular malformations determined that total excision could generally be carried out in venous malformations but that only partial excision was typically possible for lymphatic and combined vascular malformations, with lymphatic malformations in many cases not being operable at all. [24]

Previous
Next:

Follow-up

Complicated or large venous malformations are best treated at a referral center staffed by a multidisciplinary team of diagnostic and interventional radiologists, plastic surgeons, and interested ablative surgeons (eg, neurosurgery).

Previous
Next:

Complications

The type and severity of complications depend on the size and location of the malformation and type of intervention chosen. Greater complications are seen with more difficult resections that involve vital structures. Recurrence is a common complication of therapy.

A retrospective study by Fujiki et al indicated that in patients with venous malformations, treatment with the sclerotherapeutic agent 5% ethanolamine oleate in a total injected dose of 0.18 mL/kg or above is an independent risk factor for macroscopic hemoglobinuria (which can precede renal impairment). However, the investigators reported that the hemoglobinuria is reversible through aggressive hydration and administration of haptoglobin. [25]

Previous
Next:

Outcome and Prognosis

The outcome and prognosis are most closely related to the size and location of the venous malformation. The likelihood of significant perioperative morbidity and recurrence increases with more diffuse malformations and with malformations intimately involving vital neurovascular structures.

Previous
Next:

Future and Controversies

The future holds great promise for the diagnosis and treatment of all vascular malformations, including venous malformations. Advances in molecular genetics are adding to the understanding of vascular malformations and hopefully will elucidate the mechanism of origin of the developmental abnormalities associated with these anomalies. [26] Several inherited disorders have been identified and defective genes have been located. [11] Additional information is expected as work on the human genome continues. This new knowledge hopefully will elucidate the pathogenesis of vascular malformations and lead to fresh approaches to therapy. [26, 27]

The field of angiogenesis continues to mature, and new antiangiogenesis drugs are in clinical trials that may lead to fresh treatment modalities for these vascular anomalies. [26]

Previous