Balloon occlusion as an adjunctive technique during sclerotherapy of Puig's classified advanced venous malformations

Abstract

Objective Puig types 2 through 4 venous malformations (VMs) are challenging to treat with sclerotherapy given their robust systemic outflow. Endovenous balloon occlusion offers a means of temporarily occluding systemic venous outflow to allow for more complete sclerotherapy. This study reviews our experience of implementing this technique in patients with Puig advanced (types 2 through 4) VMs. Methods An IRB approved review of treated venous malformations from 2013–2016 revealed 10 patients fitting inclusion criteria. Patient demographics, pre-procedural imaging, intra-procedural technical parameters, and post-procedural follow-up outcomes were recorded. All patients underwent temporary balloon occlusion of a systemic or major draining vein during sclerotherapy. Embolic agents included n-butyl cyanoacrylate glue, sodium tetradecyl sulfate foam, and coils. Standard 5 French angioplasty balloons ranged from 4 to 8 mm diameter and 2 to 8 cm length depending on vessel requiring occlusion. All patients underwent minimum 3-year follow-up questionnaire administration re-assessing resolution of lesion symptomology and post-procedural quality of life (QoL) measures. Results Of the 10 VMs treated, 2 were Type 2, 6 were Type 3, and 2 were Type 4. More than one sclerotherapy session was required in 7/10 patients (mean: 2, range: 1–4). Most common sites of VM systemic drainage included subclavian, popliteal, internal/external jugular, and basilic veins. All patients had no indication for further sclerotherapy following adjunctive balloon occlusion. No non-target embolization or immediate post-procedural complications occurred. Follow-up questionnaires (mean interval: 3 years 6 months, range: 3 years–3 years 11 months) confirmed the persistence of embolization effects, improved QoL, and no additional sclerotherapy sessions for all patients in the cohort. Conclusions Endovenous balloon occlusion as an adjunct to sclerotherapy can be considered when treating patients with types 2–4 venous malformations. This technique lowers the risk of non-target systemic venous embolization, allowing for operator-driven deeper intralesional sclerosant penetration and subsequently maintained treatment efficacy.

An overview of interventional radiology techniques for the diagnosis and management of vascular anomalies: Part 1

“…For VM of the limbs, a tourniquet may be applied at the start of the procedure to decrease venous outflow into the normal systemic vasculature and increase contact time between the sclerosant and malformation 7 . Endovenous balloon occlusion can temporarily occlude systemic venous outflow or endovascular plugs or coils may be placed for permanent occlusion to allow for more complete sclerotherapy 19 …”

“…7 Endovenous balloon occlusion can temporarily occlude systemic venous outflow or endovascular plugs or coils may be placed for permanent occlusion to allow for more complete sclerotherapy. 19 Similarly for LM, US is used to obtain needle access into the cysts and the volume of injected sclerosant is determined by the volume of fluid decompressed and the amount of contrast injected. Small cysts are treated in a single session.…”