Percutaneous MR Imaging-Guided Laser Ablation and Cryoablation for the Treatment of Pediatric and Adult Symptomatic Peripheral Soft Tissue Vascular Anomalies

Abstract

Purpose: To evaluate the safety and effectiveness of percutaneous magnetic resonance (MR) imaging-guided laser ablation and cryoablation for the treatment of symptomatic soft tissue vascular anomalies (VAs) of the trunk and extremities.Materials and Methods: An institutional review board-approved retrospective review was undertaken of all pediatric and adult patients who underwent MR imaging-guided and monitored laser ablation and/or cryoablation for the treatment of symptomatic peripheral soft tissue VA. Preablation and postablation MR imaging was independently reviewed. Pain scores on the visual analog scale (0 to 10) and self-reported subjective symptomatic improvement were assessed. Change in VA size and pain scores were compared using a paired t test.Results: Thirty patients (24 females; age, 10-75 years) with 34 VAs were treated for moderate to severe pain (n ¼ 27) or swelling/mass effect (n ¼ 3) with 60 total ablation sessions. The baseline maximum VA diameter was 9.5 cm ± 8.6. At baseline, all VAs (100%) demonstrated variable T2-weighted signal hyperintensity and enhancement. The baseline pain score was 6.4 ± 1.6. Clinical follow-up was available for 23 patients. At a mean follow-up time of 12.2 months ± 10.1, 19 of 20 (95%) patients treated for pain and 2 of 3 (67%) patients treated for swelling/mass effect reported partial or complete symptomatic relief. There was a significant decrease in the postablation pain scores (À5.7 ± 1.0, P < .001) and maximum VA size (À2.3 cm ± 2.7, P ¼ .004), with >50% reduction in VA T2 signal (59%) and enhancement (73%). Nine of 30 (30%) patients experienced minor complications.Conclusions: MR imaging-guided and monitored percutaneous laser ablation and cryoablation appear to be safe and effective for the treatment of symptomatic peripheral soft tissue VAs. ABBREVIATIONSPeripheral soft tissue vascular anomalies (VAs) can be classified as vascular tumors, which can be benign, locally aggressive/borderline, or malignant, or as vascular malformations, which can be further subdivided into simple or combined nonneoplastic anomalies. VAs are typically sporadic and isolated but may be associated with a number of different genetic syndromes (1). VAs may not only cause pain, swelling, or cosmetic concern but also may cause more serious, potentially life-threatening problems such as highoutput cardiac failure or consumptive coagulopathy, depending on VA size, location, histopathology, and flow characteristics (2).

Magnetic resonance – guided treatment of low-flow vascular malformations and the technologies to potentiate adoption

“…Due to the adaptability of laser ablation this technique may be more effective in treating large, difficult LFVMs when compared to sclerotherapy ( 4 , 22 ). Moreover, complications associated with this treatment are rare and typically minor, including scarring, tissue necrosis, and dyspigmentation ( 25 ).…”

“…For example, in a case study from Gocal et al, they discussed the treatment of a large VM on a patient’s tongue which prevented him from closing his mouth. This patient was treated with 3 stages of laser therapy using a Nd: YAG laser with a wavelength of 1,604 nm and power of 15 W. After 3 months’ time, the patient’s lesion had been completely ablated and the patient’s tongue had returned to a normal size ( 25 ). Additionally, in a retrospective study of 176 patients with Nd: YAG laser treatment of LFVMs, Poetke et al reported good to great results in 95% of patients and reported no permanent complications ( 24 ).…”

“…Lastly, Augustine et al ( 25 ) reported treatment of a cohort of 30 patients with LFVM of the extremities and trunk who underwent 49 IMRI laser ablations, 10 cryoablations, and 1 combination treatment. Of note, 45% (27/60) of these procedures were performed partially with US guidance for device navigation, and real-time MRI for treatment monitoring while 55% (33/60) used MR for device guidance and treatment monitoring including 21 laser ablations employing MR thermometry.…”

“…This report did not compare the effectiveness of each thermal ablation modality. Regardless, it does suggest that these modalities may be similarly effective at treating moderate-to-severe pain symptoms with only minor self-resolving adverse events ( 25 ).…”

“…In a prospective trial by O’Mara et al employing this semiautomated software planning and targeting technique in a 1.5 T system, treating 22 LFVM patients across 33 procedures resulted in mean decreases in targeting time and procedure time of 25 min and 28 min, respectively ( 10 ). Along with sclerotherapy, these studies also provide promising early results for the use of this software package to assist in the placement of cryoprobes and laser probes as these thermal ablation techniques are typically associated with long procedural times which may require multiple treatment sessions ( 25 ).…”