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Background and Aims Recommendations for the treatment of lower GI bleeding do not include bleeding from venous malformations (VMs). The aim of this study was to delineate the usefulness of a novel hybrid intervention (fluoroscopy-guided endoscopic sclerotherapy) for the treatment of symptomatic VMs in the rectosigmoidal colon with bleeding. Methods The magnetic resonance images of 421 patients with VM, referred to multicenter vascular anomaly centers from 2009 to 2017, were analyzed retrospectively. Treatment was performed for all patients who experienced bleeding from rectosigmoidal VMs using fluoroscopy-guided endoscopic sclerotherapy with polidocanol foam as a novel approach. Results A total of 27 patients displayed VM in the rectosigmoidal area. Eleven of these presented with acute or previous bleeding and received treatment. Active bleeding was observed in 8 patients (72.7%), whereas 3 patients (27.3%) had signs of previous bleeding. Six of the 11 patients had anemia (54.5%). There were no adverse events within 24 hours of the intervention. In a 2-year follow-up period, only 1 patient (9.1%) presented with recurrent bleeding after 13 months and was successfully treated again with fluoroscopy-guided endoscopic sclerotherapy. Conclusions Fluoroscopy-guided endoscopic sclerotherapy was shown to be a safe and effective treatment of symptomatic VMs of the rectosigmoidal area. Thus, fluoroscopy-guided endoscopic sclerotherapy should be considered for patients with bleeding from VMs of the rectosigmoid after a comprehensive workup and interdisciplinary case discussion.

Purpose To evaluate the safety and outcome of percutaneous sclerotherapy for treating venous malformations (VMs) of the hand. Materials and Methods A retrospective multicenter trial of 29 patients with VMs primarily affecting the hand, including wrist, carpus, and/or fingers, treated by 81 percutaneous image-guided sclerotherapies using ethanol gel and/or polidocanol was performed. Clinical and imaging findings were assessed to evaluate clinical response, lesion size reduction, and complication rates. Substratification analysis was performed with respect to the Puig’s classification, the sclerosing agent, the injected volume of the sclerosant, and to previously performed treatments. Results The mean number of procedures per patient was 2.8 (± 2.2). Last follow-up (mean = 9.2 months) revealed a partial relief of symptoms in 78.9% (15/19), while three patients (15.8%) presented symptom-free and one patient (5.3%) with no improvement. Post-treatment imaging revealed an overall objective response rate of 88.9%. Early post-procedural complications occurred after 5/81 sclerotherapies (6.2%) and were entirely resolved by conservative means. Type of VM (Puig’s classification) as well as sclerosing agent had no impact on clinical response (p = 0.85, p = 0.11) or complication rates (p = 0.66, p = 0.69). The complication rates were not associated with the sclerosant volume injected (p = 0.76). In addition, no significant differences in clinical success (p = 0.11) or complication rates (p = 0.89) were detected when comparing patients with history of previous treatments compared to therapy-naive patients. Conclusion Percutaneous sclerotherapy is both safe and effective for treating VMs of the hand. Even patients with history of previous treatments benefit from further sclerotherapy showing similar low complication rates to therapy-naive patients. Level of Evidence Level 4, Retrospective study.

Purpose To prospectively evaluate the efficacy and safety of a new ethylene vinyl alcohol (EVOH) copolymer–based embolic agent in the treatment of symptomatic peripheral arteriovenous malformations (AVMs). Materials and Methods This prospective single-center study evaluated EVOH embolization with 3 different formulations of EVOH (Squid Peri 12 cP, 18 cP, and 34 cP; BALT Germany GmbH, Dusseldorf, Germany) in patients with symptomatic AVMs. Between April 2018 and October 2019, 36 embolization procedures in 21 patients (3 males and 18 females; mean age, 34.7 years) were performed (inclusion criteria: symptomatic peripheral AVM, ≥14 years of age, and elective embolization). Symptoms, technical aspects (transarterial, transvenous, or percutaneous approach; plug or balloon occlusion), clinical and technical success (defined as the improvement of symptoms and complete angiographic eradication of the AVM nidus), adverse events, and short-term outcomes were assessed. Results The mean volume of the embolic agent used per session was 3.4 mL of EVOH 34 cP (standard deviation [SD], ± 5.4), 6.2 mL ± 8.1 of EVOH 18 cP, and 4.6 mL ± 10.1 of EVOH 12 cP. Angiographic success was achieved in 18 patients (85.7%). The mean follow-up was 190 days (range, 90–538 days; median, 182 days). In the follow-up assessment, findings of magnetic resonance imaging showed that 19 patients (90.5%) had a persistent state of devascularization compared with postinterventional angiography. Amelioration or complete elimination of pain was achieved in 90.0% of the patients. One patient experienced a major adverse event; minor adverse events developed in 2 patients. Conclusions In this study, EVOH appeared to be a safe and effective embolic agent in peripheral AVMs and had a low rate of adverse events in a limited number of patients.

The aim of this retrospective cross-sectional study was to provide an MRI-based examination framework of venous malformations (VMs) infiltrating the sciatic nerve and determine the frequency of nerve infiltration patterns and muscle involvement in correlation to the patients’ quality of life. Pelvic and lower limb MR images of 378 patients with vascular malformations were examined retrospectively. Pain levels and restriction of motion were evaluated with a questionnaire. Cross-sectional areas of affected nerves were compared at standardized anatomical landmarks. Intraneural infiltration patterns and involvement of muscles surrounding the sciatic nerve were documented. Sciatic nerve infiltration occurred in 23/299 patients (7.7%) with VM. In all cases (23/23; 100%), gluteal or hamstring muscles surrounding the nerve were affected by the VM. Infiltrated nerves were enlarged and showed signal alterations (T2-hyperintensity) compared to the unaffected side. Enlarged nerve cross-sectional areas were associated with elevated pain levels. Three nerve infiltration patterns were observed: subepineurial (12/23; 52.2%), subparaneurial (6/23; 26.1%) and combined (5/23; 21.7%) infiltration. This study provides a clinically relevant assessment for sciatic nerve infiltration patterns and muscle involvement of VMs, while suggesting that VMs in gluteal and hamstring muscles require closer investigation of the sciatic nerve by the radiologist.

The aim of this study was to identify the frequency of rectosigmoidal involvement in patients with venous malformations (VM) of the lower extremities and to demonstrate multidisciplinary therapeutic options. The medical records and magnetic resonance images (MRI) of patients with VM of the lower extremities, over a six-year period, were reviewed retrospectively in order to determine the occurrence of rectosigmoidal involvement. Vascular interventions, surgical treatments, percutaneous and hybrid (endoscopy-guided angiography) sclerotherapy and procedural complications (according to Clavien-Dindo classification) were also noted. Of the 378 patients with vascular malformation of the lower limbs, 19 patients (5%) had documented venous rectosigmoidal malformation. All of these 19 patients reported episodes of rectal bleeding, while seven patients (36.8%) also had anemia. All patients underwent endoscopy. By endoscopy, seven patients (36.8%) showed discreet changes, and 12 patients (63.2%) showed pronounced signs of submucosal VM with active (47.3%) or previous (15.7%) bleeding. Treatment was performed in all patients with pronounced findings. Six patients underwent endoscopy-guided hybrid sclerotherapy, one patient underwent endoscopic tissue removal, one patient received percutaneous sclerotherapy and one patient received a combination of transvenous embolization and hybrid sclerotherapy. Three patients required open surgery. No complications occurred after conservative treatments; however, one complication was reported after open surgery. None of the treated patients reported further bleeding and anemia at the end of the follow-up period. In this cohort, rectosigmoidal VM occurred in 5% of patients presenting with a high incidence of rectal bleeding. Percutaneous or endoscopy-guided hybrid sclerotherapy appeared to be a safe and effective alternative to surgery.

Objective The aim of this study was to evaluate the safety and clinical outcomes of percutaneous sclerotherapy of venous disorders of the labia majora in patients with vascular malformations of the lower limbs. Methods Thirty percutaneous sclerotherapy treatments were performed over a 6-year period among 17 female patients with symptomatic venous malformation (VM) or secondary varicosis of the labia majora. Four patients were treated with sclerotherapy alone, 13 patients had additional procedures to control the VM before sclerotherapy. Polidocanol was used as sclerosant. Indications for sclerotherapy included pain, bleeding, thrombophlebitis, and swelling. Genitourinary symptoms were recorded. The number of treatments and procedure-related complications were registered. Complications were classified according to the Society of Interventional Radiology (SIR) classification system (grade A-E). The 3-month postintervention follow-up included magnetic resonance imaging, clinical examination, and a symptom-related questionnaire. If no reintervention was necessary, consultation was scheduled biannually. Results All patients had local swelling and pain; only a fraction of the patients had further symptoms with bleeding or thrombophlebitis (47% each). Eight patients required reintervention. No major complications were observed; minor complications such as postprocedural swelling occurred in 29% (SIR grade A), pain occurred in 17% (SIR grade B), and skin blistering developed in 5% (SIR grade B). Upon follow-up examination after a median of 40 months, 76% showed complete relief of symptoms, and 23% reported partial relief. All patients reported a substantial reduction in pain (75% >5 points in visual analogue scale) and swelling (88% complete cessation). Conclusions Percutaneous sclerotherapy is a safe and effective treatment option of VM and secondary varicosis of the labia majora.