Moderators
Ann Kulungowski, MD, and Taizo Nakano, MD
Children's Hospital Colorado, Aurora, CO
Guest Presenter
Sweccha Bhatt, MD
House Officer, Dhulikhel Hospital, Dhulikhel, Nepal
Guest Panelists
Aparna Annam, DO
Division of Pediatric Radiology, Children's Hospital of Colorado
Aurora, CO
Mandeep Guragai, MD
Global Surgery Simulationation Network, Kathmandu, Nepal
Dean Klinger, MD
Medical College of Wisconsin
Milwaukee, WI CO
Vascular Patient Cases from Nepal
Several cases of complex vascular malformations in patients ranging from 7 to 24 years old were presented. Discussions centered around diagnostic approaches, treatment options, and management strategies. The surgical team explored different therapeutic methods including sclerotherapy, interventional radiology, and surgical resection, while considering factors such as patient follow-up, anticoagulation, and the use of compression garments. The discussions emphasized the importance of proper diagnosis through imaging techniques like MRI and ultrasound,and the need for careful monitoring and follow-up to manage these vascular anomalies effectively.
Learning Objectives
- To increase awareness of pediatric patients with complex vascular anomalies internationally
- To establish proper diagnosis and treatment of vascular anomalies
- To create a forum for debate, discussion, and dialog on approaches for treating pediatric patients with pediatric anomalies
Key Takeaways
CASE 1. Child Venous Malformation Treatment Plan
Dr. Sweccha presented a case of a 7-year-old patient with a venous malformation in Nepal. She described the clinical findings, diagnostic workup, and treatment with sclerotherapy. She sought feedback on managing residual malformation and alternative sclerosing agents, as the patient hasn't shown up for follow-up. The panel, including Dr. Kulungowski, Dr. Takano, and Dr. Arnam, discussed the importance of patient follow-up and the challenges of providing optimal care for vascular anomalies in resource-limited settings.
The team discussed a case of a venous malformation in a child, focusing on diagnostic approaches and treatment options. They agreed that initial labs were within normal limits, and imaging, particularly an MRI, would be beneficial for understanding the extent of the malformation. Dr. Taizo emphasized the importance of preparing patients for procedures by considering anticoagulation, though this remains controversial. Dr. Aparna suggested using polydocanol or sodium tetradecyl sulfate as sclerosing agents, avoiding doxycycline as it is ineffective for venous malformations. The team aligned on pursuing an interventional radiology approach rather than surgery due to the extent and location of the malformation.
CASE 2. Knee Venous Malformation Treatment Discussion
The team discussed a 24-year-old patient with a right knee venous malformation that has caused swelling and pain for 18 years. Dr. Aparna suggested using compression garments and potentially working with an orthopedic surgeon for joint involvement, while Dr. Taizo emphasized the importance of early orthopedic assessment and monitoring for limb length discrepancy in similar cases. The team considered various treatment options, including sclerotherapy, surgical resection, and the use of glue embolization, with a focus on improving the patient's quality of life and managing chronic pain.
Venous Malformation Treatment Strategies
The discussion focused on the management of venous malformations, with particular emphasis on treatment options and considerations for both pediatric and adult patients. Taizo highlighted the potential use of chronic low-dose anticoagulants to reduce the frequency of thrombosis and improve quality of life, while Aparna explained the importance of venogram checks to assess the integrity of the deep venous system before and after procedures. The group also discussed the use of sirolimus for targeted therapy, noting its potential benefits in reducing coagulopathy but limited impact on bulk disease. Compression stockings and oral anticoagulants were recommended as initial therapies, with Aparna emphasizing the need for careful monitoring and follow-up if pharmacotherapy is chosen.
CASE 3. Child's Back Vascular Lesion Treatment
The team discussed a case of a 3-year-old female patient with a pulsatile, compressible but non-tender swelling on her back since 6 months of age. Dr. Nam suggested using both ultrasound and MRI for imaging, with MRI providing flow characteristics and extent of the lesion. Dr. Bhat proposed angioembolization as a treatment option, particularly if the lesion shows high flow characteristics, and mentioned potential risks like skin discoloration from using certain agents. The team also discussed the possibility of surgical resection or a combined approach, with Dr. Bhat emphasizing the importance of understanding the medication's spectrum of treatment when using substances like alcohol.
CASE 4. Vascular Anomaly Diagnosis and Monitoring
The team discussed a vascular anomaly case involving a 3-year-old patient with a growing lesion that was initially misidentified as a birthmark. After ultrasound and MRI evaluation, they determined it was likely an arteriovenous malformation (AVM) with high flow characteristics. While there was uncertainty about whether it was an infantile hemangioma or a different type of congenital hemangioma, the team agreed that if the diagnosis was confirmed, they could consider resection using a circular excision technique. The discussion concluded with recommendations to monitor the lesion's growth over time before making any treatment decisions.