jurnal nurul
DESCRIPTION
l;TRANSCRIPT
![Page 1: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/1.jpg)
NURUL AZIZAH BUSTAM
![Page 2: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/2.jpg)
BACKGROUNDAffects only 0.8% to 1% of the populationoften associated with significant lifelong
morbidityVascular anomalies may be classified as
either vascular tumors (not the subject of this study) or vascular malformations, depending on whether they are proliferative or nonproliferative.
![Page 3: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/3.jpg)
Vascular tumors
• present at birth, are• proliferative lesions• typically involute
spontaneously during childhood
Vascular malformations
• present at birth and grow at a rate similar to the patient, although they may not become clinically evident until later in life
• have normal endothelial cells and are not proliferative lesions
• do not regress but rather tend to progress over the patient’s lifetime
Vascular anomalie
s
![Page 4: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/4.jpg)
Lack of consensus regarding how to approach vascular malformations
The diagnosis and treatment of such lesions is best accomplished when they are classified based on :vascular composition (arterial, venous, lymphatic, or
combined)flow dynamics (high or low flow)
Both prognosis and treatment of vascular malformations are primarily dependent upon the velocity of flow within the lesion low-flow lesions of any type faring far better than high-flow
lesions in all regardsLow-flow vascular malformations (LFVM) are usually treated
with transcutaneous sclerotherapy and/or surgical resectionHigh-flow lesions (HFVM) usually require trans-arterial
catheter-based interventions and/or surgical resection.
![Page 5: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/5.jpg)
PURPOSEThe purpose of this study was to evaluate the
efficacy and safety of our previously described imaging protocol and therapeutic algorithm in the treatment of LFVM and HFVM in a large series of patients implemented by our multidisciplinary team.
![Page 6: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/6.jpg)
METHODSPatient selectionthe approval of the Institutional Review BoardMedical records of patients treated by the
multidisciplinary vascular malformation team at our institution directed by the senior author from January 2006 to June 2011 were analyzed.
The database is prospectively maintained and included 136 malformations in 135 patients at the time of review.
![Page 7: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/7.jpg)
Multidisciplinary approachMeets monthly to review all vascular
malformation patients. This team consists of vascular surgeons,
pediatric surgeons, adult and pediatric orthopedic surgeons, adult and pediatric plastic surgeons, adult and pediatric hematologists, adult and pediatric dermatologists, adult and pediatric ophthalmologists, and diagnostic and interventional radiologists.
![Page 8: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/8.jpg)
Classification of lesions
Vascular malformations
high-flow
include an arterial
component
low-flow
venous lymphatic combined
vascular tumors
excluded from
consideration in this
study
![Page 9: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/9.jpg)
Radiographic workupdceMRI was obtained for every patient
deemed a candidate for intervention in order to determine flow characteristics (high flow vs low flow) and extent of the lesion.
![Page 10: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/10.jpg)
TREATMENT ALGORITHM
![Page 11: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/11.jpg)
Only patients who are symptomatic or have complications of their vascular malformation are considered candidates for therapeutic intervention, given the potential for additional morbidity related to any intervention.
Such indications include hemorrhage, debilitating pain, or functional disability
For patients without a clear indication to intervene, conservative management is employed, which may entail observation alone, or compression stockings.
![Page 12: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/12.jpg)
Evaluation of outcomesPatients were assessed at multiple time
points beginning with their initial evaluation.An outcomes grading system based on
patient-and physician-derived treatment goals emphasis on changes in symptoms and functional status (1 worse; 2 unchanged; 3 significantly improved; 4 completely resolved).
Patients were evaluated postprocedurally in the clinic between procedures as necessary and within 4 weeks of the final procedure.
![Page 13: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/13.jpg)
RESULTSDuring the 5½-year period, 135 patients with
136 vascular malformations were evaluated and treated by the multidisciplinary vascular malformation team at our institution.
The 59 (43.7%) males and 76 (56.3%) females ranged in age from 1 day to 68 years (mean, 25.3 17.0 years) at the time of initial evaluation.
![Page 14: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/14.jpg)
![Page 15: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/15.jpg)
![Page 16: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/16.jpg)
DISCUSSIONIt is important to note that only those patients meeting
criteria for intervention are considered candidates for therapeutic intervention.
Indications for intervention may include the following conditions or complications of VMs: bleeding;signs and symptoms of chronic venous insufficiency (painful
varicosity, edema, skin changes, ulcers, recurrent superficial thrombophlebitis);
lesions located at a life threatening region involving or close to vital structures (e.g., proximity to the airway), or located in an area threatening vital functions (e.g., sight, eating, hearing, or breathing);
disabling pain:
![Page 17: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/17.jpg)
functional impairment (e.g., genital region);cosmetically severe deformity;lesions located at regions with high risk of
complications (e.g., hemarthrosis, thromboembolism);lesions combined producing the vascularbone
syndrome (length discrepancy of the lower extremities, affecting the bone itself) or the destructive angiodysplastic arthritis(Hauert disease);
lesions obstructing the outflow and drainage of vital organ (i.e., liver, brain);
persistent lymph leak due to a combined lymphatic malformation lesion with/without infection;
recurrent sepsis, local and/or general, due to a combined lymphatic malformation lesion.
![Page 18: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/18.jpg)
The most agreed upon factor leading to successful management of patients with vascular malformations is the multidisciplinary approach.
Utilizing the multidisciplinary approach to individualize treatment algorithms, conservative management is appropriate for patients with tolerable symptoms and uncomplicated lesions, as these patients are unlikely to progress clinically and would not benefit from therapeutic intervention.
![Page 19: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/19.jpg)
Further, in our cohort, patients with low-flow lesions are treated with sclerotherapy (foam and/or ethanol), primary resection, or a combination of modalities with improvement in symptoms and attainment of patient and physician directed goals of therapy in 87.5% of patients.
High flow lesions are also managed successfully, with symptomatic improvement in 89.5%.
![Page 20: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/20.jpg)
Due to the lower efficacy and higher complication rate of ethanol compared to foam, we advocate the use of foam as the initial treatment of low-flow lesions, reserving ethanol primarily for patients who do not experience an adequate response to foam.
![Page 21: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/21.jpg)
CONCLUSIONSThis study provides strong evidence that experienced
providers working in the context of a coordinated and structured multidisciplinary team can treat these complex patients successfully.
Once hemodynamic physiology is discerned, focused, and individualized treatment strategies can be applied.
Patients with both LFVM and HFVM can be managed to attain treatment goals set by both the patient and provider.
For low-flow lesions in particular, we recommend consideration of foam as the initial treatment, reserving ethanol for patients who do not achieve their goals of therapy with foam-based agents.
![Page 22: JURNAL NURUL](https://reader035.vdocuments.site/reader035/viewer/2022081506/563dbafa550346aa9aa9387c/html5/thumbnails/22.jpg)
Thank you