Combined Nd:YAG laser and bleomycin sclerotherapy under the same anesthesia for cervicofacial venous malformations: A safe and effective treatment option
Introduction
Venous malformations (VM) are the 3rd most common type of vascular anomaly seen in the head and neck, behind hemangiomas and lymphatic malformations. A VM is comprised of connections of abnormal, dilated slow flow blood vessels. These arise as a result of disordered vasculogenesis, caused by somatic mutations in TIE2 (endothelial cell tyrosine kinase receptor causing more than half of sporadically occurring VMs) and PIK3CA (gene encoding the catalytic p11α subunit of PI3K) [1]. Mutations result in chronic or hyper-activation of these pathways, dysregulation of angiogenic factors and abnormal endothelial and mural cell morphology, including uncontrolled growth [1]. These lesions are present at birth but often go unrecognized until childhood or even adulthood depending on size and location. Proper initial diagnosis is key as these lesions grow with the patient over time and will not involute or resolve on their own. They may expand rapidly due to hormonal changes (e.g. puberty or pregnancy), thrombophlebitis, following trauma or even after treatment attempts. Because the venous channels in these lesions are so distensible, pooling and stasis of blood occurs resulting in thrombus formation, often presenting as a palpable firm mass on exam and causing acute episodes of pain for the patient.
Treatment options include surgical resection, sclerotherapy (ST) and laser therapy (LT). Surgery can be difficult or even inadvisable, especially in the case of large cervicofacial VM (CFVM) due to their infiltrative nature into surrounding tissues and vital neurovascular structures. LT with Nd:YAG has shown excellent results in control of lesions involving mucosal surfaces of the oral cavity, oropharynx, hypopharynx and larynx. However, this does not address the deeper, larger venous pools that may be more symptomatic. This is where sclerotherapy plays a role. Ultimately, a multimodal approach is often required to optimize results.
Unfortunately, combination therapies often result in the need for multiple separate trips to the operating room and interventional radiology suite to alternate the laser and ST sessions. At our institution, it has become standard practice to perform the laser and ST sessions under the same general anesthetic event. We sought to retrospectively review our case series to determine the overall success and safety profile of this approach as it has not yet been described in the literature.
Section snippets
Materials and methods
IRB exemption was obtained through the Children's Hospital of Wisconsin (CHW) IRB for a retrospective review of all cases of combined ST and LT of VMs performed under the same anesthetic administration from January 2014 through May 2017. Patient demographics (age at presentation and time of treatment as well as sex) were collected along with any associated symptoms, extent of involvement of the VM and history of previous treatment(s) and associated complications. For the treatment sessions,
Results
There were a total of 8 patients (6 females, 2 males) who underwent combined treatment modalities under a single anesthetic for their CFVMs (see Fig. 1). Age at time of first treatment ranged from 6 months to 74 years (mean 31). All patients had upper airway complaints, most often OSA or dysphagia. The majority of the patients had received previous treatments at other institutions. Patient 2 and 7 had suffered significant morbidity as a result of prior treatments (Table 1). All but one patient
Discussion
Historically, surgical resection was the mainstay of treatment for large VMs of the head and neck region. However, this result in significant morbidity and high complication rates given the propensity of VMs to infiltrate surrounding tissues and be in close proximity to vital neurovascular structures. In recent years there has been an inclination for less invasive approaches especially in the cases of large CFVMs. The treatment of these lesions is dictated by several factors, which have been
Conflicts of interest
None.
References (8)
- et al.
Somatic activating PIK3CA mutations cause venous malformation
Am. J. Hum. Genet.
(2015) - et al.
Sclerotherapy for low-flow vascular malformations of the head and neck: a systematic review of sclerosing agents
J. Plas. Rec. Aesth. Surg.
(2016) - et al.
Endoscopic transmucosal direct puncture sclerotherapy for management of airway vascular malformations
Laryngoscope
(2015) - et al.
Nd:YAG laser (1-64 nm) in the treatment of venous malformations of the face and neck: challenges and benefits
Laser Med. Sci.
(2007)
Cited by (6)
Effect of foam and liquid bleomycin in the management of venous malformations in head and neck region: A comparative study
2020, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :All patients were injected in the outpatient clinic requiring only topical anesthetic cream, precluding the risk of anesthesia and also saving the cost of a long hospital stay. In our study, we did use the traditional method of injection as described in previous studies;28–43 this is a relatively easy and cost-effective method but needs a good level of experience. Hence, ultrasound-guided injection would be more helpful to know that we are in the correct space while injecting the sclerosing agent,44 and we could consider this as a possible limitation of the study.
Multimodality treatment of vascular anomalies of the head and neck
2022, Journal of Oral Pathology and MedicineManagement of Venous Malformations
2021, Seminars in Interventional RadiologyContemporary Management of Vascular Anomalies of the Head and Neck - Part 1: Vascular Malformations: A Review
2021, JAMA Otolaryngology - Head and Neck SurgeryProgress in evidence-based research on the clinical treatment of infantile hemangioma and vascular malformations
2021, Journal of Prevention and Treatment for Stomatological Diseases