sonographically guided percutaneous sclerosis using 1% polidocanol in the treatment of vascular...

Sonographically Guided PercutaneousSclerosis Using 1% Polidocanol in theTreatment of Vascular Malformations

Rajeev Jain, MD,1,2 Suman Bandhu, MD,1 Sukhpal Sawhney, MD,1 Ravi Mittal, MS3

1 Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India2 Department of Radiology, College of Medicine, P.O. Box 35, Sultan Qaboos University, Al Khod 123, Oman3 Department of Orthopedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India

Received 30 July 2001; accepted 2 April 2002

ABSTRACT: Purpose. The aim of this prospective

study was to assess the safety and efficacy of sono-

graphically guided percutaneous injection of 1% poli-

docanol for sclerosis of peripheral vascular malforma-

tions.

Methods. Patients with vascular malformations of

soft tissues were invited to enroll in the study. Gray-

scale and color Doppler sonography were performed

to determine the texture, margins, and size of the le-

sions and to determine whether high-velocity blood

flow was present. Using real-time sonographic guid-

ance, lesions were punctured with a 20/21-gauge spi-

nal needle. When possible, venous return was oc-

cluded before injection. For each injection, 1–6 ml of

1% polidocanol was injected into 1 or more sites

within the lesion. The sclerosing agent was not aspi-

rated after injection. Repeat radiography was per-

formed 1 month after each injection session. The pro-

cedure was repeated if the patient did not have a

complete response, defined as an 80% or greater de-

crease in the volume of the lesion or resolution of the

presenting symptoms.

Results. Of the 15 patients enrolled, 9 had venous

malformations, 3 had lymphangiomas, 1 had a recur-

rent aneurysmal bone cyst, 1 had a venous pseudo-

aneurysm, and 1 had an arteriovenous malformation

of the pinna. Each patient received 1–20 injections of

1% polidocanol (mean ± standard deviation, 3.3 ± 4.8

injections). This treatment resulted in a complete re-

sponse of 7 venous malformations, 3 lymphangio-

mas, and the arteriovenous malformation and partial

response of 2 venous malformations, the recurrent

aneurysmal bone cyst, and the venous pseudoaneu-

rysm. Only minor complications occurred.

Conclusions. Sonographically guided percutane-

ous injection of 1% polidocanol for sclerosis of periph-

eral vascular lesions is simple, effective, and safe. This

technique is especially effective in cases of soft tissue

venous malformation and lymphangioma. © 2002

Wiley Periodicals, Inc. J Clin Ultrasound 30:416–423,

2002; Published online in Wiley InterScience (www.

interscience.wiley.com). DOI: 10.1002/jcu.10091

Keywords: vascular malformation; lymphangioma;

aneurysmal bone cyst; ultrasonography; intervention;

sclerotherapy

Vascular malformations of soft tissues arecommon and usually congenital. Symptoms

of vascular malformations include cosmetic disfig-urement, pain, limitation of function, and bleed-ing. The established modes of treatment are sur-gical excision and, more recently, transluminalvascular embolization for hypervascular lesions.Surgical excision frequently results in incompleteremoval of the lesions and often worsens the cos-metic appearance. Transarterial embolization ismost effective in cases of arterial malformationthat have a few, easily accessible feeding vessels.

Several vascular sclerosants have been usedfor percutaneous sclerosis of vascular malforma-tions. Most of these sclerosing agents act by dam-aging the vascular endothelium and intima andcausing subsequent thrombotic occlusion. Onepercent polidocanol (hydroxypolyaethoxydodecan;Aethoxysklerol, Kreussler Pharma, Wiesbaden,Germany) has been safely used for the sclerosis ofgastroesophageal varices,1 endoscopic injection ofintestinal vascular malformations,2 cutaneoushemangiomas,3 and ectatic veins.4,5 We present

Correspondence to: R. Jain

© 2002 Wiley Periodicals, Inc.

416 JOURNAL OF CLINICAL ULTRASOUND

the results of a prospective study of sonographi-cally guided direct percutaneous puncture andsclerosis using this agent in patients with variousvascular malformations.

PATIENTS AND METHODS

Patients 7–30 years old who visited the surgicaland orthopedic clinics of our hospital over a pe-riod of 18 months for evaluation or treatment ofperipheral vascular malformations were referredto the radiology department for possible inclusionin a prospective trial of percutaneous sclerosis ofthese lesions. Patients with deep visceral lesionswere excluded from the study. The ethics commit-tee of our institution had approved the use of 1%polidocanol for percutaneous sclerosis of vascularmalformations. Written informed consent was ob-tained from all patients or their legal guardians.

All patients had undergone preliminary sonog-raphy, CT, MRI, or angiography studies, and theresults of these examinations were reviewed be-fore sclerotherapy. All lesions were reassessed us-ing gray-scale and color Doppler sonography, per-formed with a Sonoline Versa Pro ultrasoundscanner (Siemens, Issaquah, WA) and an HDI3000 ultrasound scanner (Advanced TechnologyLaboratories, Bothell, WA) equipped with a5–7.5-MHz linear-array transducer to evaluatethe extent and size of each lesion, its relationshipto adjacent structures, and its vascularity (includ-ing feeding vessels and blood flow velocity) and toplan a safe percutaneous approach for injectingthe sclerosing agent.

Before each injection, the skin was cleanedwith 10% povidone iodine solution and draped us-ing all precautions to ensure aseptic conditions.After induction of local analgesia, sonographicallyguided direct percutaneous puncture of the lesionwas performed with the freehand technique, us-ing a 20/21-gauge spinal needle with a stylet. Forall peripheral lesions in the extremities, a bloodpressure cuff was placed proximal to the mostproximal aspect of the lesion and inflated to apressure of 60 mm Hg just before the injection of1% polidocanol. This compression was performedto occlude venous return and to prevent rapid out-flow of the sclerosing agent into the drainingveins.

For each injection, approximately 1 ml of 1%polidocanol was injected for each centimeter ofthe diameter of the lesion, with a maximum of 6ml. Before injection, the calculated volume of 1%polidocanol was mixed with 0.2–1.0 ml of 1% li-docaine solution to minimize pain after injectionof the sclerosing agent. Injection of the sclerosant

was guided by real-time sonography, and then theneedle was withdrawn. We did not attempt to as-pirate either the contents of the lesions before in-jection or the sclerosing agent after injection. Twominutes after the injection, the blood pressurecuff was gradually deflated. In cases of multilocu-lated lesions and large, infiltrative lesions, mul-tiple injections were administered during a singlesession.

To compress the lesion and appose its walls,the lesion was covered with a wad of cotton woolor surgical gauze and then with a pressure ban-dage, which was removed after 24 hours. The pa-tient received oral analgesics on demand and wasobserved for 6 hours after the injection. If no com-plications that required further management oc-curred, the patient was discharged from the hos-pital with instructions to report any excessivepain, redness, or swelling at the injection site;pain in the limb proximal to the lesion; or othercomplications. Patients were also advised to re-turn after 1 month for clinical and radiographicfollow-up.

Follow-up gray-scale and color Doppler sonog-raphy was performed in all patients at the1-month follow-up visit, before subsequent ses-sions of sclerotherapy, and at the conclusion oftherapy. For the last 5 patients accrued, all ofwhom had undergone MRI studies beforetherapy, we also obtained MRI studies at the endof therapy. The volumes of the lesions were cal-culated before and after sclerotherapy.

We arbitrarily defined cure or complete re-sponse as the resolution of the presenting symp-toms or at least an 80% decrease in the volume ofthe lesion. Partial response was defined as per-sistence of symptoms or less than an 80% de-crease in the volume of the lesion. Injections wererepeated at monthly intervals in patients who didnot show a complete response, clinically accept-able resolution of symptoms, or clinically accept-able reduction of the lesion size.

RESULTS

Over the 18-month period, 15 patients with vas-cular malformations were referred to us for per-cutaneous sclerotherapy. The patients’ character-istics and results of the study treatment aresummarized in Table 1. The underlying lesionswere venous malformation of a limb (9 patients),lymphangioma of the neck or thigh (3 patients),recurrent aneurysmal bone cyst of the distal ra-dius (1 patient), posttraumatic venous pseudoan-eurysm (1 patient), and arteriovenous malforma-

PERCUTANEOUS SCLEROSIS IN VASCULAR MALFORMATIONS

VOL. 30, NO. 7, SEPTEMBER 2002 417

tion of the pinna (1 patient). Twelve of the 15patients had peripheral lesions in the extremities.The clinical symptoms and indications for sclero-therapy included cosmetic disfigurement (9 pa-tients), pain (8 patients), and limitation of func-tion (5 patients). The lesions ranged in diameterfrom 1.5 to 8.0 cm (mean ± standard deviation[SD], 3.6 ± 1.8 cm), excluding 1 very large lesionthat involved the entire forearm. The volumes ofthe remaining 14 lesions (assuming an ellipsoidshape) ranged from 1.2 to 38.4 ml (mean ± SD,16.0 ± 14.7 ml).

A single injection resulted in complete resolu-tion of the lesions in 4 patients. Each of the other11 patients received 2–20 injections (mean ± SD,3.3 ± 4.8). Larger lesions were injected 2–5 timesat different sites, either at a single session or atdifferent sessions.

Sonographically guided percutaneous punctureand subsequent injection of the sclerosing agentwas successful in all patients. Complete resolu-tion occurred in 11 (73%) patients, and partialresponse occurred in 4 (27%) patients. The bestresponses occurred in the patients with venousmalformations or lymphangiomas. Of the 9 pa-tients with venous malformations, 7 showed acomplete response (Figure 1). All 3 patients withcosmetic disfigurement showed appreciable im-provement in the cosmetic appearance of the le-sion (Figure 2). Similarly, all 3 of the patientswith lymphangiomas had a complete response(Figure 3).

In 1 patient, who had experienced blunt

trauma to the wrist, we observed a compressibleswelling with slow filling when the wrist was in adependent position and reversal of swelling whenthe wrist was raised. Gray-scale and color Dop-pler sonographic examination demonstrated onlyvenous flow in the lesion and emptying of theblood through the forearm veins on compression.A diagnosis of venous pseudoaneurysm was con-sidered, and sclerotherapy was attempted. Aftersclerotherapy with 2 injections, initial thrombosisof the lesion was observed. The patient had a par-tial response, with a 67% reduction in the volumeof the lesion and alleviation of the associatedpain.

At 6 months’ follow-up, the patient who hadbeen treated for a recurrent aneurysmal bone cystin the distal radius showed no increase in the sizeof the lesion. Radiography revealed visible thick-ening and sclerosis of the walls and septa of thelesion; this was considered a partial response.The patient with an arteriovenous malformationof the pinna showed pulsatile swelling with high-velocity flow on color Doppler sonographic stud-ies. Immediately before injection of 1% polidoca-nol, a solitary large draining arterialized vein wasmanually compressed, and the pressure was re-lieved 1 minute after injection. After 2 injections,the lesion showed complete thrombosis and ab-sence of pulsatility.

All patients with soft tissue lesions who under-went sclerosis reported that the lesions becamefirm, noncompressible, and tender in the initial

TABLE 1

Results of Sonographically Guided Percutaneous Sclerosis Using 1% Polidocanol

PatientNo.

Age,Years

ClinicalDiagnosis Location

Diameter,cm

InitialVolume, ml

FinalVolume, ml

%Reduction

No.Injections

Follow-up,Months Response

1 10 Venous malformation Foot 2.5 17.3 1 94.3 1 2 Complete

2 11 Venous malformation Leg 2 5 0 100 1 3 Complete

3 12 Venous malformation Leg 4 6.5 2.6 60 2 3 Partial

4 16 Venous malformation Forearm Large* — — — 20 9 Complete

5 22 Venous malformation Forearm 4 15.8 1.8 88.6 2 6 Complete

6 23 Venous malformation Forearm 4 16 0 100 2 4 Complete

7 25 Venous malformation Leg 1.5 1.2 0 100 1 4 Complete

8 28 Venous malformation Palm 6 38.4 8 79.2 3 5 Partial

9 30 Venous malformation Forearm 2 8.1 0.1 98.8 1 4 Complete

10 7 Lymphangioma Thigh 5 35 0.5 98.6 6 15 Complete

11 18 Lymphangioma Neck 8 48 1.9 96.1 3 2 Complete

12 27 Lymphangioma Neck 2 4 0 100 2 3 Complete

13 8 Aneurysmal bone cyst,

recurrent

Radius 3 20.3 20 2.3 2 6 Partial

14 28 Venous pseudoaneurysm Wrist 3 6 2 66.7 2 2 Partial

15 18 Arteriovenous

malformation

Pinna 3 3 0 100 2 2 Complete

Mean† 18.9 3.6 16.0 2.7 84.6 3.3 4.7

SD† 7.9 1.8 14.7 5.4 27.1 4.8 3.5

Abbreviation: SD, standard deviation.

*This lesion was too extensive and ill defined for measurement.†Calculated values are based on lesion measurements of all patients except patient 4.

JAIN ET AL


period after sclerosis and that resolution of thesesymptoms occurred over the next 4–6 weeks.These initial symptoms are likely due to the in-duced thrombosis in the lesions and subsequenthealing.

Complications noted in the study were minor.The most frequent complication was superficialerythema and induration of the skin, which oc-curred in 4 patients: the patient with a venouspseudoaneurysm, 2 patients with venous malfor-mations, and 1 patient with a lymphangioma. Allthese lesions were superficially located withinsubcutaneous soft tissues, and the complicationswere likely caused by irritation and an inflamma-tory reaction secondary to leakage of the scleros-ing agent. In each case, this complication lastedfor 4–6 days and resolved completely without spe-cific therapy. No ulceration of the skin occurred inany patient. The patient with a venous pseudoan-eurysm had thrombophlebitis of the major drain-ing vein to the elbow, which resolved within 2

weeks. No other complications related to distantor nontarget organ embolization or sclerosis oc-curred. None of the complications required medi-cal therapy or hospitalization.

DISCUSSION

Our results show that sonographically guidedpercutaneous sclerotherapy of vascular malfor-mations using 1% polidocanol is safe and effec-tive.

Various authors have classified vascular mal-formations on the basis of flow rates6 and havedistinguished between hemangiomas and vascu-lar malformations on the basis of histopathologicfeatures.7 Vascular malformations have been fur-ther differentiated into capillary, arterial, ve-nous, lymphatic, or combined types. In addition tothese types, aneurysmal bone cysts (primary) arelined with endothelium and are considered peri-

FIGURE 1. (A) T2-weighted MRI scan of a transverse section of the right forearm of a 30-year-old man shows a hyperintense lesion (arrows) deep

within the flexor compartment anterior to the radius (R). U, ulna. (B) Transverse sonogram of the forearm shows a heterogeneous venous

malformation (arrows) within the flexor compartment. R, radius. (C) Follow-up transverse sonogram of the forearm 4 months after percutaneous

sclerotherapy with 1% polidocanol shows marked reduction in the size of the lesion (arrows), near-complete disappearance of the vascular spaces,

and increased echogenicity. The patient’s symptoms resolved completely. R, radius.



FIGURE 2. (A) Photograph of the right forearm and hand of a 16-year-old girl shows a large, disfiguring venous

malformation. (B) T2-weighted MRI scan of a transverse section of the mid forearm shows the extensive

venous malformation (curved arrows), which contains phleboliths, within the subcutaneous tissues and mus-

cular compartments. (C) Photograph of the patient’s forearm after 20 injections, at 9 months’ follow-up, shows

marked cosmetic improvement.


osteal or intraosseous vascular malformations.8

The 2 features common to all vascular malforma-tions are their persistence and their progressivegrowth.

The established method for treatment of vas-cular malformations is surgical excision. How-ever, this approach is often associated with cos-metic disfigurement and frequently results inincomplete removal of these lesions owing to their

infiltrative nature, inaccessibility, or proximity tovital neurovascular structures. Intra-arterialtransluminal embolization of vascular malforma-tions is an alternative technique that is most ef-fective for lesions with a high rate of blood flowand an arterial supply from only a few branchesthat can all be accessed and occluded safely(ie, arterial vascular malformations). Vascularmalformations supplied by numerous arterial

FIGURE 3. (A) Sagittal sonogram of the anterior aspect of the thigh of a 7-year-old girl shows a lymphangioma

(arrows) containing large cystic spaces. (B) Sagittal sonogram after 6 injections, at 15 months’ follow-up,

shows marked regression in the size of the lesion (arrows), increased echogenicity, and absence of large cystic

spaces. Marked cosmetic improvement was noted.



branches or unidentifiable feeding vessels cannotbe treated with this approach.

Polidocanol acts as an endothelial irritant thatinduces thrombosis and subsequent fibrosisaround the vascular spaces into which it is in-jected. In addition, because polidocanol has an an-esthetic effect, injection of this agent is almostpainless. In this study, we added a small volumeof 1% lidocaine to the injected solution to ensurethe patients experienced minimal pain.

Absolute alcohol is an easily available and in-expensive sclerosant, but it has a very strong ad-ditional necro-inflammatory effect. In a compara-tive study of alcohol, polidocanol, and otherinjectable sclerosants for obliteration of esopha-geal varices,9 alcohol was as effective as the otheragents for thrombosis but was associated with un-acceptable adverse effects. Of all the sclerosantstested, alcohol was associated with the highestincidence and severity of esophageal ulcers, me-diastinitis, and fistulas. Polidocanol was as effec-tive as alcohol but was much safer, with minimaladverse effects.9 Our current observations con-firm that polidocanol is an effective sclerosantthat is associated with minimal pain and compli-cations.

In our study, the best results were observedamong the 9 patients with venous malformations,7 of whom had complete response to treatment.This finding was not unexpected because theselesions have extremely slow blood flow, whichpermits prolonged contact of the sclerosing agentwith the endothelium. Furthermore, because ve-nous malformations are compressible lesionswhose cavity walls are apposed to one another,sclerosis and obliteration are enhanced and re-canalization is prevented.

Similar results occurred among patients withlymphangiomas. However, these lesions are usu-ally larger and more infiltrative than venous mal-formations and often have noncommunicatingspaces that may necessitate repeated injectionsinto each isolated cavity. Aspiration of the con-tents of lymphangioma cysts before injection of asclerosing agent has been shown to cause the cav-ity to collapse and to prevent dilution of the in-jected agent.10 The fact that we did not aspiratethe contents of the lymphangiomas might explainwhy the patients with these lesions had a slowerresponse than did the patients with venous mal-formations.

In the patient with a recurrent aneurysmalbone cyst, puncture with subsequent injection ofthe sclerosing agent was successful. Follow-up ra-diography performed 6 months after the proce-dure showed that the lesion size remained stable,

with appreciable thickening and sclerosis of theinvolved cortex and internal septa. One previousreport on percutaneous direct puncture and injec-tion of a sclerosing agent into aneurysmal bonecysts has been published.11 Embolization with analcoholic solution of zein resulted in radiographi-cally confirmed resolution in 14 (87%) of 16patients and partial improvement in the other 2patients (13%). Those authors recommendedlong-term follow-up of patients with these lesions,with repeat injections at intervals of at least 6months to allow for mineralization and healingbefore assessment of response to treatment.11

In this study, we successfully performed scle-rosis of an arteriovenous malformation of thepinna. We believe that in cases of visceral lesionsin which venous return cannot be effectively con-trolled and in which a high rate of blood flowcould cause rapid outflow of the sclerosant intothe draining veins, percutaneous sclerosis islikely to be ineffective and could result in compli-cations. A proposed alternative technique for per-cutaneous sclerosis of peripheral arterial lesionsin the extremities is to use a blood pressure cuff tocompress the lesion and to minimize its volume. Asecond blood pressure cuff is placed proximal tothe lesion and inflated to a pressure higher thanthe patient’s systolic blood pressure to occludefurther blood flow to the lesion. The first bloodpressure cuff is then removed, and percutaneoussclerosis of the lesion is performed using a proce-dure similar to that used for other types of le-sions.

Real-time sonographic guidance in percutane-ous sclerosis is simple, safe, and cost-effective andcan often be performed bedside. The main advan-tages of sonography over other guidance modali-ties are the abilities to perform imaging in realtime and to monitor the paths of needles, otherinstruments, and injected substances. The advan-tages of direct-puncture percutaneous sclero-therapy are its ease, efficacy, and safety. More-over, in cases of incomplete response or residualor recurrent malformations, the procedure caneasily be repeated. Whenever possible, percutane-ous sclerosis should be attempted as the first lineof therapy for vascular malformations because ofits excellent results and minimal complications.In cases in which this technique fails, vascularembolization or surgery can still be performed.

In conclusion, sonographically guided percuta-neous puncture and sclerosis using 1% polidoca-nol is effective and safe for the treatment of low-flow vascular malformations, with a high successrate and minimal complications. This technique isalso effective in the sclerosis of lymphangiomas

JAIN ET AL


and venous ectasia or pseudoaneurysms. Furtherstudy is needed to determine the role of this tech-nique for sclerosis of aneurysmal bone cysts andarterial malformations.

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2. Jaspersen D, Korner T, Schorr W, et al. Diagnosisand treatment control of bleeding colorectal angio-dysplasias by endoscopic Doppler sonography: apreliminary study. Gastrointest Endosc 1994;40:40.

3. Winter H, Drager E, Sterry W. Sclerotherapy fortreatment of hemangiomas. Dermatol Surg 2000;26:105.

4. Yamaki T, Nozaki M, Sasaki K. Color duplexguided sclerotherapy for the treatment of venousmalformations. Dermatol Surg 2000;26:105.

5. Duffy DM, Garcia C, Clark RE. The role of sclero-

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6. O’Donovan JC, Donaldson JS, Morello FP, et al.Symptomatic hemangiomas and venous malforma-tions in infants, children and young adults: treat-ment with percutaneous injection of sodium tetra-decyl sulphate. AJR Am J Roentgenol 1997;169:723.

7. Mulliken JB, Glowacki J. Hemangiomas and vas-cular malformations in infants and children: a clas-sification based on endothelial characteristics.Plast Reconstr Surg 1982;69:412.

8. Mirra JM. Bone tumours: clinical, radiologic andpathologic correlations. Philadelphia: Lea and Fe-biger; 1989. p 1233.

9. Acharya SK, Dasarathy S, Bhargava DK. Alcoholis not a desirable sclerosant. Indian J Gastroen-terol 1990;9:83.

10. Dubois J, Garel L, Abela A, et al. Lymphangiomasin children: percutaneous sclerotherapy with an al-coholic solution of zein. Radiology 1997;204:651.

11. Guibaud L, Herbretean D, Dubois J, et al. Aneu-rysmal bone cysts: percutaneous embolization withan alcoholic solution of zein—series of 18 cases.Radiology 1998;208:369.



sonographically guided percutaneous sclerosis using 1% polidocanol in the treatment of vascular...

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