Slerotherapy for venous malformations

Percutaneous Sclerotherapy For
Spongiform Venous Malformations
Analysis of Patient-evaluated
Outcome And Satisfaction.
Clemens RK, Baumann F, Husmann M,
Meier TO, Thalhammer C, MacCallum
G, Ruth Amann-Vesti B, Alomari AI.

Percutaneous sclerotherapy for spongiform venous malformations - analysis of
patient-evaluated outcome and satisfaction.
Clemens RK, Baumann F, Husmann M, Meier TO, Thalhammer C, MacCallum G,
Ruth Amann-Vesti B, Alomari AI. Vasa. 2017 Aug 25:1-7.
doi: 10.1024/0301-1526/a000650.
Sclerotherapy of venous malformations is safe
and significantly reduces symptoms with
almost no or minimal major complications.

© 2017 Hogrefe Vasa (2017),1–7
https://doi.org/10.1024/0301-1526/a000650
1
Original communication
Percutaneous sclerotherapy for
spongiform venous malformations –
analysis of patient-evaluated
outcom e and satisfaction
Robert Karl Clemens1,2,Frederic Baumann1,Marc Husmann1,Thomas Oleg Meier1,
Christoph Thalhammer1,Gail MacCallum2, Beatrice Ruth Amann-Vesti1,
and Ahmad Ibrahim Alomari2
1
Clinic for Angiology, University Hospital and University Zurich,Zurich, Switzerland
Division of Vascular and Interventional Radiology,Boston Children’s Hospital and Harvard Medical School, Boston,USA2
Summary: Background: Congenital venous malformations are frequently treated with sclerotherapy. Primary treatment goal is
to control the often size-related symptoms. Functional impairment and aesthetical aspects as well as satisfaction have rarely
been evaluated. Patients and methods: Medical records of patients who underwent sclerotherapy of spongiform venous mal-
formations were reviewed and included in this retrospective study. The outcome of sclerotherapy as self-reported by patients
was assessed in a 21 item questionnaire. Results: Questionnaires were sent to 166 patients with a total of 327 procedures.
Seventy-seven patients (48 %) with a total of 159 procedures (50 %) responded to the survey. Fifty-seven percent of patients
were male. The age ranged from 1 to 38.1 years with a median age of 16.4 years. The lower extremities were the most common
treated area. Limitations caused by the venous malformation improved in the majority of patients (e.g. pain improvement 87 %,
improvement of swelling 83 %) but also worsening of symptoms occurred in a minority of cases. Seventy-seven per cent would
undergo sclerotherapy again. Conclusions: Sclerotherapy for treatment of venous malformations results in signiﬁcant reduc-
tion of symptoms. Multiple treatments are often needed, but patients are willing to undergo them.
Keywords: Venous malformation, sclerotherapy, satisfaction
patterns of VMs, which may present in various ways and
extensive size, irrespective of any anatomical boundaries
[9–11].
Conservative treatment includes compression gar-
ments, which are also used additionally to “active” inva-
sive treatment depending on the site of the lesion. First-
line treatment of VMs is sclerotherapy despite conflicting
data [12]. Sclerotherapy is recommended in venous mal-
formations of type I and II according to Puig et al., who
classify type I as isolated malformations without peripher-
al drainage, type II as malformations that drain into nor-
mal veins, type III as malformations that drain into dilated
veins, and type IV as malformations that represent dys-
plastic venous ectasia [12]. While Berenguer et al. reported
male gender and number of sclerotherapy sessions as in-
dependent predictors for good outcomes, Yun et al. report-
ed lower numbers of sclerotherapy and female gender as
predictive factors for good responses to percutaneous
sclerotherapy in VMs [13, 14]. The question remains, which
Introduction
Venous malformations (VM) are the most common vascu-
lar malformation and are rarely hereditary [1–3]. In over
90 % of patients, VMs show a progressive course over life-
time accompanied by an increase of symptoms [2]. In con-
sequence, invasive treatment is indicated to relief patients
from discomfort, which is primarily pain [4]. Some forms
of VM, for instance when involving the airways or with
articular involvement, disfigurement, and gastro-intesti-
nal bleeding, need treatment even in the absence of pain
[5–7]. Venous malformations are also often part of com-
plex or combined vascular syndromes [8]. The primary
goal of treatment is controlling of symptoms related to the
lesion size, anatomical location, and the adjacent anatomi-
cal structures that may be affected. Complete cure is rarely
possible, making the disease a lifelong issue for patients,
frequently requiring recurrent interventions, as surgery is
also limited in its efficacy based on the morphological
http://econtent.hogrefe.com/doi/pdf/10.1024/0301-1526/a000650-Saturday,August26,20173:16:52AM-UZHHauptbibliothek/ZentralbibliothekZürichIPAddress:144.200.17.42

2 R.K.Clemens et al., Patient satisfaction in sclerotherapy
Vasa (2017),1–7 © 2017 Hogrefe
patients respond well to sclerotherapy and which factors
may be predictive for complications. In addition, data on
clinical outcomes and patients’ satisfaction after sclero-
therapy for VMs are scarce [15].
The purpose of this study was to assess pain relief, im-
provement in functional outcomes, and changes in quality
of life following sclerotherapy for the treatment of VMs.
Patients and methods
Study design
This is a retrospective, questionnaire-based cohort study.
A total of 166 patients with spongiform venous malforma-
tions were analysed, which constitutes the most common
form of VMs [16].
Imaging studies including CT, MRI, and ultrasound of
all VM procedures treated by sclerotherapy and performed
from April 2004 through January 20 13 were reviewed and
categorized based on the type of malformation. Paediatric
radiologists with experience in the diagnosis of vascular
anomalies confirmed the diagnosis, performed morpho-
logical assessment (i.e. extent, size), and classified the
type of VM.
Vascular malformations not classified as spongiform
were excluded, for the remaining cases, medical records
were reviewed to obtain further information. This includ-
ed demographics, presenting symptoms at baseline, and
medical history. Demographic and clinical data extracted
from medical records and imaging studies included age,
sex, type and anatomic location of the VM, and number of
sclerotherapy treatments. All VM procedures were per-
formed by sclerotherapy and by the same interventional
radiologist with much experience in the treatment of
vascular anomalies at a tertiary referral hospital.
This study was performed after being reviewed and
accepted by the local ethic committee and is in accordance
with the Declaration of Helsinki.
Spongiform venous malformations
Spongiform VMs are dilated veins with thin walls and
abnormal smooth muscle tissue that has the angiographic
appearance of a sponge. They show very low flow and tend
to form clots whose remnants are called phleboliths. Ana-
tomical regions of VM location and treatment were cate-
gorized as: 1. Head/ neck, 2. Upper extremities, 3. Lower
extremities, 4. Torso, 5. Multiple locations.
Sclerotherapy of vascular malformations
Treatment was performed with ultrasound (GE LOGIQ )
and fluoroscopy-guided sclerotherapy performed accord-
ing to previously reported techniques [17]. The majority of
procedures were carried out with the patient under general
anaesthesia. If the patients were older and able to under-
stand the procedure, local or none anaesthesia was first
choice in the treatment of VMs [18]. Fluid-filled venous
spaces were cannulated with 20 -gauge or 21-gauge nee-
dles under ultrasound guidance [19]. A small amount of
contrast medium was injected into the VM to confirm
ap- propriate placement of the needle and to avoid non-
target injection. The lesion size was estimated by the
volume of contrast agent used to fill the VM. Dehydrated
ethanol was regularly opacified with the addition of oily
contrast medium (e.g. Ethiodol at a 5:1 ratio; Savage
Laboratories, Mel- ville, NY). Sodium tetradecyl sulfate
3 % (STS) may be used in foam or liquid form. In detail,
STS opacified with Ethiodol (5:1 ratio) added to the same
volume of air can be foamed by exchanging the mixture
between the syringes through a three-way stopcock. The
lipiodized oil increases the stability of the foam.
Frequently, the dual-needle tech- nique, where one
needle is used to drain the lesion and another to inject
the sclerosant is applied [20]. To avoid leakage of the
sclerosant, manual compression was applied at the
puncture sites after needle removal. Complica- tions were
documented using the Quality Improvement Guidelines
for the Reporting and Archiving of Interven- tional
Radiology Procedures [21].
Questionnaire
All patients identified with spongiform malformations
were provided with a questionnaire (ESM 1) and asked for
completion. All first questionnaires were sent out in 2012.
If patients did not respond to the first questionnaire, they
were sent a second questionnaire after three months. If
they did not respond to the second questionnaire, they
were contacted via phone or email and, provided the
patient agreed, a third questionnaire was sent.
The questionnaire was specifically designed for patients
with spongiform VMs complaints and treatment often dif-
fers from other types of venous malformations. The ques-
tionnaire was based on a previously used and published
questionnaire that assessed patient-evaluated improve-
ment after percutaneous sclerotherapy for lymphatic
malformations [15].
The questionnaire included the following categories:
physical, psychological (emotional), and social limitations.
The intention of the questionnaire was to assess the
subjective impact of the VM treatment and the physical
categories pain, swelling, cosmetic appearance, bleeding,
muscle/ joint concerns, and interference with everyday
activities. Patients with muscle/ joint concerns had either
VM involvement of the joints or joint bleeding, causing
swelling or pain, or were affected by the VM in their move-
ment when physically engaged i.e. sour feeling or pain in
the muscle that contained the VM.
Patients were asked to describe the degree of improve-
ment after sclerotherapy on a subjective five-grade scale
(complete/excellent, good, fair, minimal/ no response, or

R.K.Clemens et al., Patient satisfaction in sclerotherapy 3
© 2017 Hogrefe Vasa (2017),1–7
worse). Response was defined as improvement of the
symptom(s) for which the patient sought treatment. Com-
plete or excellent response signified 90 –100 % improve-
ment; good, 50–90 %; fair, 25–50 %; and minimal/no
response, less than 25%.
When symptoms were perceived to have worsened, pa-
tients were asked to classify treatment response as worse.
If patients were uncertain or did not remember the degree
of response, they classified their response as “don’t know”
or “don’t remember”. Complications after sclerotherapy
and previous medical or surgical treatments were catego-
rized as binary responses (yes/ no) with additional multiple
choice questions for clarification in the case of affirmative
answers.
The questionnaire consisted of three parts based on the
chronology of assessment (ESM 1):
a. Assessment prior to sclerotherapy
These questions referred to information at baseline
prior to sclerotherapy including: physical VM-associat-
ed symptoms such as pain, swelling, size, anatomical
localization, and the psychological burden due to disfig-
urement or affected appearance and associated physical
limitations, leading to isolation and embarrassment.
b. Assessment following each sclerotherapy procedure
These questions referred to procedure-related compli-
cations as well as continuing VM-related discomfort
after sclerotherapy.
c. Current assessment
This part referred to the present day (at the time of the
questionnaire completion), and assessed long-term
effects of sclerotherapy and overall patient satisfaction.
All responses were entered in the Research Electronic
Data Capture (REDCap) database (www.project-redcap.org).
Quality control (Q / C) was assured through back-checking
of entered data in RedCap against the original question-
naires. The entries were double-checked by a second
investigator. Incomplete, incorrect, inaccurate, and irrele-
vant data were removed from the final database to ensure
accuracy and completeness.
Questionnaires were sent to 166 VM patients under-
going a total of 327procedures.
Not all patients answered all parts correctly. All descrip-
tions of symptoms were described but only completely
filled out questionnaires were compared.
Demographics and risk factors as well as the anatomical
localization of the VMs are outlined in Table I. The lower
extremities and head/ neck were the most frequently
affected and treated locations of VMs.
Results
Seventy-seven patients with a total of 159 procedures
responded to the questionnaire. This is a resonance rate of
46.4% with 48.6 % of procedures performed. The median
time between the last procedure and the time of question-
naire was 3.39 ± 2.36 years. Out of the 77 patients, only
eight patients completed the questionnaire in less than six
months, 11 patients in six to 12 months, and the remaining
58 patients in more than 12 months after the last proce-
dure. Overall, 57 % of patients were female with a median
age of 16.4 years. Baseline characteristics are depicted in
Table II.
1. Pre- vs. post-limitations
a. Physical limitations: Treatment improved physical limi-
tations in 34 out of 50 (68 %) patients, and for six (12 %)
patients physical limitations became worse after treat-
ment. They remained unchanged for 10 (20
%) patients.
b. Emotional limitations: Treatment improved emotional
limitations in 34 out of 55 patients (62 %), and for six
patients (11 %) physical limitations became worse after
treatment. They remained unchanged for 15 (27 %)
patients.
c. Social limitations: Treatment improved social limita-
tions in 29 (64 %) patients and for five patients (6 %)
social limitations became worse after treatment. They
remained unchanged for 11(24%) patients.
Table III gives an overview of limitations in patients with
VMs.
Table I. Types of venousmalformations basedon angiographic appear-
ance.
I.Spongiform type
II.Phlebectatic type III
Aneurysmatic type
IV Reticular type
Table II. Baseline characteristics.
No.of patients
Sex male/female
Age
Median age
Prior treatment
77 (100)
44/33 (57%/43%)
1–38.1 years
16.4 years
45 (58%)
Number of treatments
1
2–3
4–5
>5
32
44
7
2
Area treated (total numbersof treatments)
Head/neck
Upper extremities
Lower extremities
Torso
Multiple locations
20 (49)
10 (18)
30 (64)
8 (16)
6 (12)

Vasa (2017),1–7 © 2017 Hogrefe
2. Factors on which the decision to seek
treatments was based, and related post-
treatment outcomes
a. Pain: 69 patients based their decision to seek treatment
for their VM partly on their pain level. For 60 (87 %)
patients, pain either decreased or was eliminated after
treatment. For seven out of 69 patients (10 %) pain was
worse at the time of reporting. For two (3 %) patients
who had decided to undergo treatment in part based on
their pain level, treatment had no effect on their pain.
b. Swelling: 73 patients based their decision to seek treat-
ment partly on their level of swelling. Following treat-
ment, 24 patients (32 %) reported no swelling. In 37 pa-
tients (51 %), swelling improved but was not eliminated
completely. In 61 patients (83 %) swelling either de-
creased or was entirely eliminated following treatment.
For seven patients (10 %) swelling became worse fol-
lowing treatment. For five patients who had made the
decision to undergo treatment in part based on their
level of swelling treatment had no related effect.
c. Cosmetic appearance: 49 patients based their decision
to seek treatment partly on cosmetic reasons. In 42
(86 %) patients, cosmetic concerns either decreased or
were eliminated following treatment. In four (8 %)
patients, their cosmetic concerns increased following
treatment. In three (6 %) patients who had decided to
undergo treatment based on cosmetic concerns, experi-
enced no change following treatment.
d. Bleeding: 17 patients based their decision to seek treat-
ment partly on bleeding. For 16 patients (93 %) patients,
bleeding either decreased or was eliminated following
treatment. No patient had worse bleeding after treat-
ment. For one patient who had decided to
undergo treatment partly due to bleeding, treatment
had no effects on this symptom.
e. Muscle/Joints: 36 patients based their decision
to undergo treatment partly on muscle/ joint concerns.
For a total of 26 of patients (72 %) their muscle/ joint
concerns either decreased or were eliminated
following treatment. For six (17 %) patients muscle/ joint
concerns increased following treatment. For two (6
%) patients who had decided to undergo treatment
partly due to muscle/ joint concerns, treatment had no
effect on these symptoms.
f. Interference with everyday activities: 58 patients sought
treatment partly due to the interference of their malfor-
mation with everyday activities. Following treatment, 33
(57%) patients had no limitations in everyday activity.
For 20 patients (34 %), treatment reduced but did not
eliminate the inference of their malformation with every-
day activities. For five patients (9 %) treatment increased
interference. For three (5 %) patients whose decision was
based on interference of the malformation with everyday
function, treatment had no effect on his parameter.
Table IV gives a detailed overview of the results after
sclerotherapy in VMs.
Overall patient satisfaction: Data were available for
74 patients, 39 % were “extremely satisfied”, 27 % were
“very satisfied”, and 17 % were “moderately satisfied”,
10 % were only “somewhat satisfied” and 3 % “not at all
satisfied”.
Patients were asked whether they would
undergo sclerotherapy again. Overall, 77 % answered
“yes”, 18% “probably”, and 5% “no”.
As VMs located in the “same” anatomical side in differ-
ent patients may cause different symptoms and may react
differently to treatment, we did not split the VMs
into subgroups for analysis, since the results are not
fully comparable.
Discussion
Venous malformations consist of blood-filled venous
spaces and can be classified according to the International
Society for the Study of Vascular Anomalies (ISSVA) that
was revised in 20 14 [22, 23]. Approximately 93 % of VMs
progress over lifetime with pain and swelling being the
most common symptoms [2]. Lesions can be multifocal,
but the singular spongiform type is the most common type
[24]. Treatment of spongiform VMs with sclerotherapy
technically has a success rate of close to 100 % [25]. Treat-
ment goal is controlling of symptoms related to the loca-
tion of the VM. Patients and caregivers should be aware
that there is often need of multiple treatment sessions.
Measuring treatment efficacy via imaging is difficult,
due to changes in the lesion size and the need for radiation
Table III. Limitations in patients with venous malformations.
Total None Mild Moderate Severe
n patients n (%) n (%) n (%) n (%)
Physical limitations 77 27 (35) 14 (18) 28 (36) 8 (11)
Emotional limitations 74 19 (26) 26 (35) 17 (23) 12 (16)
Social limitations 77 32 (42) 22 (28) 16 (21) 7 (9)

© 2017 Hogrefe Vasa (2017),1–7
(CT), contrast agents (CT/MRI) or lengthy procedures
(MRI), which often require sedation in children [26, 27].
Even if swelling and cosmetic appearance are related to
size, pain is related to inflammation caused by local throm-
botic events. Large VMs tend to painful thrombotic events
more frequently than smaller lesions [28].
The efficacy of sclerotherapy for VMs is difficult to eval-
uate, as standard assessment criteria are missing [19]. In
addition, symptoms vary due to lesion size or location.
Size reduction after treatment may not be associated
with a relevant benefit, whereas no size reduction after
treatment may result in reduction of symptoms [14, 15].
While some authors evaluate overall patient satisfaction
using a self-assessment questionnaire, others attempt to
quantify morphologic response [29]. Given the possible
discrepancy between the clinical and morphologic re-
sponse, there are arguments for both methods [14, 30]. As
an argument for patients to undergo sclerotherapy, satis-
faction based on self-assessment seems to be a
useful instrument, since all studies show comparable
satisfaction in up to 80 % of cases, as Nakamura et al.
could show in their cohort of 40 patients [31].
Questionnaires are a proven method to measure
the subjective outcome and satisfaction after
sclerotherapy [15]. In our cohort, 46 % of patients
responded to the questionnaire. Pain and swelling were
the most common reasons for patients to seek treatment.
Van der Linden et al. included a subgroup of
venous malformations in their analysis of vascular
anomalies and were able to show that patient satisfaction
was correlated to long-term outcome [27]. These patients
were older as the patients in our cohort (no patients
under 18 years) but their findings could be confirmed in
our cohort. Van der Linden et al. achieved an
improvement of clinical symptoms in 87 % of
patients within three months and a sustainable
improvement for half of the patients during a five-year
follow-up period. In total, 40 % of patients expe- rienced
complications and 53% of patients were satisfied
with the treatment. Rautio et al. showed that the quality of
life did improve after treatment, especially if patients were
followed by a specialized clinic in a cohort of 23 patients
[22]. Long-term control could be achieved in about 55 % in
this cohort. Berenguer et al. reported an overall degree of
satisfaction with the treatment of craniofacial venous mal-
formations in children and adults in 78 % of patients [11].
Our cohort showed according data with a satisfaction of
83 %. Nakamura et al. conducted a questionnaire study to
assess clinical outcomes and predictors of patient satisfac-
tion for percutaneous sclerotherapy for venous malforma-
tions in the extremities [25]. In total, 40 out of 48 patients
answered the questionnaire. These patients received a
mean of 2.6 sclerotherapy sessions. They reported similar
results for pain improvement (83 %) and reduction of
swelling (83 %), but lower aesthetic improvement (50 %),
compared to the presented cohort.
Permanent worsening may be discussed as being part
of the natural progression. Hassanein et al. could show
that symptoms caused by low flow vascular malforma-
tions, such as VMs and LMs, progress in over 90 % during
lifetime [2, 32]. Progression was more likely in adoles-
cence than in childhood. Diffuse VMs progressed more
often than localized lesions. Risk of progression is higher
in adolescence. The mechanism of progression is not ful-
ly understood, but as VMs of the lower extremity progress
more than those of the head and neck region, the reason
could be the same as in varicose veins i.e. elevated venous
pressure causing distension and stasis that lead to clot-
ting and related pain. An increase of symptoms for up to
three months, like swelling or pain, can be expected in
large lesions after treatment and is not to be considered a
complication or treatment-related worsening. Complica-
tion rates in children treated with sclerotherapy are fre-
quent [29]. Major complications are reported in 10–30 %
[33]. Another recent study by Aronniemi et al. showed an
overall complication rate per procedure of 12.5 % [34].
Common complications of sclerotherapy include nerve
Table IV. Results after sclerotherapy.
Total
n patients
Improvement
n (%)
Unchanged
n (%)
Worsening
n (%)
Physical limitations 50 34 (68) 10 (20) 6 (12)
Emotional limitations 55 34 (61) 17 (30) 4 (9)
Social limitations 45 29 (64) 11 (24) 5 (6)
Pain 69 60 (87) 2 (3) 7 (10)
Swelling 75 61 (83) 7 (9) 7 (9)
Cosmetic appearance 49 42 (85) 3 (6) 4 (9)
Bleeding 17 15 (93) 2 (7) 0 (0)
Muscle/joint involvement 36 27 (76) 2 (6) 7 (17)
Interference with everyday activities 58 51 (87) 2 (5) 5 (8)

Vasa (2017),1–7 © 2017 Hogrefe
damage, skin necrosis and infection. They are related to
the VM site and treatment agent. Approximately 90 % of
VMs have superficial parts that involve the skin [24]. The
structure of the skin is abnormal in these cases, just leav-
ing a small layer of cells above the malformation. This
abnormal skin is therefore involved in the treatment.
Blistering, ulceration, and even scarring should be ex-
pected in these lesions when treated.
Limitations
A limitations to our analysis is the poor response to the
mailed questionnaire, as 54 % of the study participants
did not respond. All analyses are therefore based on the
returned questionnaires and were evaluated retrospec-
tively. The number of 77 responding patients is relatively
small. We did not investigate the possibility of
nonre- sponse bias. This means, that there is a
possibility that only patients, who were in general more
content with the treatment, responded to the
questionnaire, while unsatis- fied patients did not.
Another study limitation is that patient satisfaction
may underestimate or overestimate the actual physical
outcome results after treatment, as ad-hoc scales were
used to assess various symptoms. Since some
interventions were performed more than seven years ago,
patients may have had forgotten minor
complications leading to a recall bias. As only spongiform
VMs were included in our cohort, our results are not
generalizable for other types of venous malformations,
such as the phlebectatic or aneurysmal type VMs.
Because VMs can be located in the “same” anatomical
side in different patients, while causing different
symptoms and possibly respond differently to treatment,
we did not split the VMs into subgroups for analysis, as
the results are not fully comparable. After all, 77 % of
patients in our cohort would undergo sclerotherapy again.
Conclusions
Sclerotherapy for VMs reduces symptoms and therefore
improves quality of life in the majority of patients, but
worsening is also possible. Most patients need to undergo
multiple treatments but are usually willing to do so.
Electronic supplementary material
The electronic supplementary material is available with
the online version of the article at http://dx.doi.org/
10.1024/ 0301-1526/a000650
ESM 1. Questionnaire.
Questionnaire on outcome of sclerotherapy.
References
1. Boon LM, Mulliken JB, Vikkula M, et al. Assignment of a locus
for dominantly inherited
venous malformations to chromosome 9p. Hum Mol Genet
1994; 3: 1583–7.
2. Hassanein AH, Mulliken JB, Fishman SJ, et al. Venous malfor-
mation: risk of progression during childhood and adolescence.
Ann Plast Surg 2012; 68: 198–201.
3. Dompmartin A, Vikkula M, Boon LM. Venous malformation:
update on aetiopathogenesis, diagnosis and management.
Phlebology 2010; 25: 224–35.
4. Mulliken JB, Fishman SJ, Burrows PE. Vascular anomalies.
Curr Probl Surg 2000; 37: 517–84.
5. Blaise S, Charavin-Cocuzza M, Riom H, et al. Treatment of low-
flow vascular malformations by ultrasound-guided sclerother-
apy with polidocanol foam: 24 cases and literature review. Eur
J Vasc Endovasc Surg 2011; 41: 412–7.
6. Ohlms LA, Forsen J, Burrows PE. Venous malformation of the
pediatric airway. Int J Pediatr Otorhinolaryngol 1996; 37:
99–114.
7. Upton J, Taghinia A. Special considerations in vascular anoma-
lies: operative management of upper extremity lesions. Clin
Plast Surg. 2011; 38: 143–51.
8. Clemens RK, Pfammatter T, Meier TO, et al. Combined and
complex vascular malformations.VASA 2015; 44: 92–105.
9. Fevurly RD, Fishman SJ. Vascular anomalies in pediatrics. Surg
Clin North Am 2012; 92: 769–800.
10. Hill RA, Pho RW, Kumar VP. Resection of vascular malforma-
tions.J Hand Surg 1993; 18: 17–21.
11. Hein KD, Mulliken JB, Kozakewich HP, et al. Venous malforma-
tions of skeletal muscle. Plastic and reconstructive surgery
2002; 110: 1625–35.
12. Puig S, Aref H, Chigot V, et al. Classification of venous malfor-
mations in children and implications for sclerotherapy. Ped
Rad 2003; 33: 99–103.
13. Berenguer B, Burrows PE, Zurakowski D, et al. Sclerotherapy of
craniofacial venous malformations: complications and results.
Plast Reconstr Surg 1999; 104: 1–11.
14. Yun WS, Kim YW, Lee KB, et al. Predictors of response to percu-
taneous ethanol sclerotherapy (PES) in patients with venous
malformations: analysis of patient self-assessment and imag-
ing.J Vasc Surg 2009; 50: 581–9.
15. Alomari AI, Karian VE, Lord DJ, et al. Percutaneous sclerothera-
py for lymphatic malformations: a retrospective analysis of
patient-evaluated improvement.JVIR2006; 17: 1639–48.
16. Clemens RK, Pfammatter T, Meier TO, et al. Vascular malforma-
tions revisited. VASA 2015; 44: 5–22.
17. Ali S, Weiss CR, Sinha A, et al. The treatment of venous malfor-
mations with percutaneous sclerotherapy at a single academ-
ic medical center.Phlebology 2016; 31: 603–9.
18. Aronniemi J, Castren E, Lappalainen K, et al. Sclerotherapy
complications of peripheral venous malformations. Phlebology
2016; 31: 712–22.
19. Rautio R, Saarinen J, Laranne J, et al. Endovascular treatment
of venous malformations in extremities: results of sclerothera-
py and the quality of life after treatment. Act Rad 2004; 45:
397–403.
20. Puig S, Aref H, Brunelle F. Double-needle sclerotherapy of lym-
phangiomas and venous angiomas in children: a simple tech-
nique to prevent complications.AJR2003; 180: 1399–401.
21. Cardella JF, Kundu S, Miller DL, et al. Society of Interventional
Radiology clinical practice guidelines. JVIR2009; 20: 189–91.
22. Garzon MC, Huang JT, Enjolras O, et al. Vascular malforma-
tions:Part I.J Am Acad Dermatol;56: 353–70.
23. Miller DD, Gupta A. Histopathology of vascular anomalies:
update based on the revised 2014 ISSVA classification. Semin
Cutan Med Surg 2016; 35: 137–46.
24. Boon LM, Mulliken JB, Enjolras O, et al. Glomuvenous malfor-
mation (glomangioma) and venous malformation: distinct
clinicopathologic and genetic entities. Arch Derm 2004; 140:
971–6.

© 2017 Hogrefe Vasa (2017),1–7
25. Burrows PE, Mason KP. Percutaneous treatment of low ﬂow
vascular malformations.JVIR 2004; 15: 431–45.
26. Chaudry MI, Manzoor MU, Turner RD, et al. Diagnostic imaging
of vascular anomalies.FPS2012; 28: 563–74.
27. Jarrett DY, Ali M, Chaudry G. Imaging of vascular anomalies.
Derm Clin 2013; 31: 251–66.
28. Dompmartin A, Acher A, Thibon P, et al. Association of localized
intravascular coagulopathy with venous malformations. Arch
Derm 2008; 144: 873–7
29. van der Linden E, Pattynama PM, Heeres BC, et al. Long-term
patient satisfaction after percutaneous treatment of periph-
eral vascular malformations.Radiology 2009; 251: 926–32.
30. Tan KT, Kirby J, Rajan DK, et al. Percutaneous sodium tetrade-
cyl sulfate sclerotherapy for peripheral venous vascular mal-
formations:a single-center experience. JVIR2007; 18: 343–51.
31. Nakamura M, Osuga K, Maeda N, et al. Percutaneous sclero-
therapy for venous malformations in the extremities: clinical
outcomes and predictors of patient satisfaction. Springerplus
2014; 3: 520.
32. Hassanein AH, Mulliken JB, Fishman SJ, et al. Lymphatic mal-
formation: risk of progression during childhood and adoles-
cence.J Craniofac Surg 2012; 23: 149–52.
33. Uehara S, Osuga K, Yoneda A, et al. Intralesional sclerotherapy
for subcutaneous venous malformations in children. Ped Surg
Int 2009; 25: 709–13.
34. Aronniemi J, Castren E, Lappalainen K, et al. Sclerotherapy
complications of peripheral venous malformations. Phlebology
2015, 31(10):712–22.
Submitted:30.03.2017
Accepted after revision: 30.05.2017
There are no conﬂicts of interest existing.
Correspondence address
Dr.Robert Clemens
Clinic for Angiology
University Hospital Zürich
Rämistrasse 100
8091 Zürich
Switzerland
robert.clemens@usz.ch

Slerotherapy for venous malformations

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Slerotherapy for venous malformations

Similar to Slerotherapy for venous malformations (20)

Recently uploaded

Recently uploaded (20)

Slerotherapy for venous malformations