AJR 2003; 180:1399-1401
© American Roentgen Ray Society
Double-Needle Sclerotherapy of Lymphangiomas and Venous Angiomas in Children: A Simple Technique to Prevent Complications
Stefan Puig1,2,
Hussein Aref1,3 and
Francis Brunelle1
1 Department of Pediatric Radiology, Necker Hôpital Enfants Malades, 149
Rue Sevres, Paris 75015, France.
2 Present address: Department of Radiology, University of Vienna, Waehringer
Guertel 18-20, 1090 Vienna, Austria.
3 Present address: Department of Radiology, University of Alexandria, 1 Khartoum
Sq., Alexandria, Egypt.
Received December 14, 2001;
accepted after revision October 17, 2002.
Address correspondence to S. Puig.
Introduction
Percutaneous sclerotherapy involves the injection of a sclerosing substance
intravascularly for the purpose of eradicating an abnormal blood vessel.
Percutaneous sclerotherapy is a well-established method for the initial
treatment of low-flow vascular malformations such as venous or lymphatic
malformations. The percutaneous injection of pure ethanol is the preferred
approach by many and has a high success rate
[1]. The technique includes the
direct puncture of the lesion under clinical or imaging localization. To
achieve a satisfactory result, prolonged contact of the sclerosant with the
endothelial lining of the lesion is required. However, prolonged contact is
associated with a risk of extravasation of the sclerosant, which would result
in an embolization of other than the targeted volume and potential neuropathy,
tissue necrosis, or peripheral nerve palsy
[1,
2,
3,
4,
5,
6]. If the alcohol enters the
systemic vascular system, complications such as hypotension and various
degrees of intoxication or even death may occur
[3,
4,
5]. However, precisely because
of its extremely powerful sclerosing properties, ethanol has proven to be
efficacious in the treatment of vascular malformations. To reduce the risk of
ethanol reflux into the superficial veins or the central venous system, we
developed a technique whereby ethanol is drained via a second needle. The
purpose of this article is to describe this new double-needle technique.
Materials and Methods
Since 1998, we have used the double-needle technique in 15 children with
small, medium, and large vascular malformations. The malformations were
located on the head or neck in seven patients (47%), on the trunk in two
(13%), at the upper extremity in one (7%), and at the lower extremity in five
(33%). All procedures were performed with the patient under general
anesthesia. Because of the broad range of lesion sizes, a therapeutic outcome
was considered satisfactory when a notable reduction in the volume of the
vascular malformation was achieved.
After localization, a 22-gauge catheter is inserted into the lesion under
fluoroscopic control. Phlebography, using a nonionic contrast medium,
visualizes the true extent of the malformation and its hemodynamic
characteristics. A second needle of the same size is then inserted into the
lesion at some distance from the first needle to allow a rinsing flow of the
liquid (Figs. 1A,
1B and
2). An initial check should
guarantee that the contrast material is actually flowing out through the
second needle. If the drainage is not sufficient, the second needle should be
repositioned at another site under fluoroscopic control. A sclerosing agent is
then injected. The overall injected volume depends on the size of the lesion
but does not exceed the recommended dose of 1 mL/kg of body weight
[2,
5]. Using digital subtraction
angiography, we observed a direct visual correlation. During injection, liquid
flows out through the second needle; when the injection is stopped, the
outflow of liquid also ceases (Figs.
1A,
1B). The lesion filled with
contrast material is used as a mask for digital subtraction angiography.
Because of the injection of the sclerosing agent, the pressure in the lesion
increases, and the liquid in the lesion flows along the path of least
resistance. The liquid, which is a mixture of blood, ethanol, and contrast
material, becomes visible under fluoroscopy when it enters the second needle
but is also seen when it drains into the adjacent venous system. Thus, it is
quite easy to control the flow of the sclerosing agent and, if reflux into the
central venous system occurs, the procedure can be stopped immediately.
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Fig. 1B. —Treatment of venous malformation in 7-year-old boy. Digital
subtraction angiogram shows contrast material being administered via 22-gauge
catheter (arrow). Note second needle (arrowhead) inserted
into lesion. During injection of ethanol, residual contrast material flows out
through second catheter. After ethanol has penetrated lesion, fluid exits
venous malformation through second needle. No contrast material or ethanol
enters normal adjacent veins.
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When the lesion is located on a limb, a tourniquet can be used to exclude
the vascular malformation from the rest of the venous system to provide
additional safety. After the interventional procedure, all patients are
hospitalized for observation for 24 hr and then are discharged if no
complications occur. Analgesic therapy is administered for 8 days. Clinical
follow-up took place 2 months after the procedure for patients living locally.
Patients from abroad were followed up with correspondence.
Results
At our institution, 15 vascular malformations in two infants and 13 boys
and girls (nine male, six female; age range, 7 months-17 years; mean age, 6.1
years) were treated using the double-needle technique. In each case, the
greatest recommended dose of ethanol was injected within the limit of 1 mL/kg
of body weight. The desired treatment result (i.e., partial or total reduction
of the volume of the vascular malformation) was achieved in all 15 patients.
No evident extravasation of alcohol occurred, nor were minor or major
complications observed in any patient. In no case was a repetition of
sclerotherapy or other treatment required. All patients were discharged after
24 hr of observation.
Discussion
As a treatment agent for percutaneous sclerotherapy, ethanol combines the
benefits of wide availability, low cost, and powerful sclerosing properties
[3]. Complications of ethanol
injection include local tissue damage and potentially disastrous systemic
effects. Local skin and nerve injuries are avoided by ensuring that the
sclerosant remains intravascular and does not extravasate. Systemic
complications are minimized by limiting the total dose of injected ethanol to
1 mL/kg of body weight. With the double-needle technique, the flow of ethanol
is controlled locally by fluoroscopic visualization of the mixture with
contrast material and systemically by ethanol leaving the lesion through the
second needle.
The volume and pressure of blood in the vascular malformation and the
adjacent venous system are important variables. Pressure in veins under static
conditions is roughly equal to the pressure of blood reaching from the point
of measurement to the level of the heart. For example, the mean pressure in
the popliteal vein in young healthy persons in the horizontal position
measures about 12 mm Hg [7].
When a vein or venous malformation is elevated above the level of the heart,
the intravascular pressure and volume may approach zero
[8]. The pressure of injection
exerted through the syringe can easily exceed the pressure in the veins
adjacent to and connected to the malformation. If that happens, sclerosing
material will flow into the adjacent vessels. When the double-needle technique
is used, the pressure in the second needle corresponds to the atmospheric air
pressure, which is lower than the pressure in the adjacent and communicating
venous system, provided the malformation is below the level of the heart.
Patients in whom the lesion is located above the level of the heart should be
properly positioned before the intervention is begun.
During injection, the presence of the second needle allows the outflow of
contrast material or alcohol without significant elevation of the pressure in
the lesion (Figs. 1A,
1B and
2). The injected liquid will
follow the path of least resistance. Therefore, ethanol should exit the lesion
via the second needle without entering in the adjacent vessels. It is
important to verify that there is free return from the second needle during
the injection into the first. In patients in whom flow is not optimal, the
needle should be repositioned or replaced. Although lymphatic malformations
may sometimes be drained and injected through a single needle, these lesions
are similarly treated using the double-needle technique because many of them
are mixed lesions and others may not be known to be lymphatic alone before the
injection.
It is difficult to evaluate our results using this technique in a small
sample of pediatric patients. The vascular malformations varied in size and
anatomic location, and no known parameters are used to assess therapeutic
efficacy. However, in all patients, the goal of reduction of lesion size was
achieved without complications.
In conclusion, our double-needle technique showed promising results. Larger
studies are necessary to determine the advantages of this technique over other
sclerotherapeutic methods.
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Introduction
Materials and Methods
