Imaging and percutaneous treatment of vascular anomalies

Abstract

Vascular anomalies are an extensive group of malformations of the arterial, venous, and lymphatic systems, either in isolation or, more often, in combination. Although mostly congenital, they can occasionally be acquired as well. They present a challenge both for workup and therapy. This article attempts to describe some of their main anomalies, their workup, and their therapies, with the goal of increasing the comfort level of endovascular therapists.

Keywords: Vascular anomalies; embolization; hemangiomas; malformations; percutaneous endovascular therapy.

Figure 1

Digital subtraction angiography of a thigh arteriovenous malformation shows a nidus (arrow) with multiple feeders from the profunda femoris and superficial femoral artery.

Figure 2

Left external carotid angiogram showing direct shunting from arterial branches to venous sinus without presence of a nidus is suggestive of a dural arteriovenous fistula.

Figure 3

Axial contrast-enhanced computed tomography of the pelvis shows a nidus with dilated vessels in the right adnexa (double arrow).

Figure 4

Three-dimensional computed tomography angiography of face shows an arteriovenous malformation involving the left orbit. Feeding vessels (arrowheads) and nidus (arrow) are clearly depicted.

Figure 5

Coronal T2-weighted magnetic resonance imaging of gluteal region showing a large arteriovenous malformation with hypointense areas (arrow) is suggestive of flow voids, indicating high flow.

Figure 6

Color Doppler ultrasound of the pelvis (right adnexa) showing a large hypervascular area with aliasing in the high-flow areas (arrow) is suggestive of an arteriovenous malformation.

Figure 7

Postembolization angiogram of thigh arteriovenous malformation (AVM) shows nonfilling of the AVM with Onyx and glue casts seen (arrowheads).

Figure 8

Magnetic resonance T2 fat-saturated image shows an extensive upper extremity venous malformation that extends into the chest wall. Note the involvement of the underlying muscles in the upper extremity.

Figure 9

Color Doppler ultrasound of a venous malformation in the dorsum of the foot. Note lack of aliasing, indicating slow flow in contrast to arteriovenous malformations.

Figure 10

Coronal contrast enhanced computed tomography of a noninvoluting congenital hemangioma involving the left lateral cheek and temporal region shows an intensely enhancing mass (*) with a feeder vessel (arrow).

Figure 11

Venogram in a patient with Parks-Weber syndrome shows anomalous deep venous anatomy. This was in addition to the high-flow lesions (not shown).

Figure 12

Spot image during angiogram for preoperative embolization shows a large facial venous malformation with liquid embolic material (arrow) in it.

Figure 13

Venogram during sclerotherapy of a venous malformation shows venous channels and lakes.

Figure 14

(A) Contrast-enhanced axial computed tomography through the neck shows a large nonenhancing cystic mass consistent with cystic hygroma. (B) Mixed macro- and microcystic lymphatic malformation. T1-weighted coronal shows the macrocystic portion as high signal, with the superficial microcystic portion minimally hyperintense to muscle. (C) Ultrasound shows the more homogeneous macrocystic portion containing swirling proteinatious fluid, with superficial microcystic region.

Figure 15

Lateral spot image during injection sclerotherapy shows the sclerosant opacified with contrast outlining the different cystic compartments (arrows).

Figure 16

Axial (A) and coronal (B) T1 fat-saturated postcontrast images. A large enhancing mass is seen in the left lobe of the liver (arrow). Selective left hepatic angiogram shows classical peripheral filling (C) of this mass, and a subsequent image (D) shows early filling of the venous outflow in the form of the dilated left hepatic vein (double arrows).

Figure 17

Axial postcontrast fat-saturated T1-weighted image through the thigh shows an enhancing lesion in the left lateral thigh with phleboliths (arrows) in it.

Figure 18

Noncontrast axial computed tomography of the mandible shows a soft tissue mass in the superficial tissues with a phlebolith (arrow) in it suggestive of a hemangioma.

Figure 19

Flowchart provides a sample protocol for managing vascular anomalies, including multidisciplinary workup and treatment for vascular anomalies. IH, infantile hemangioma; MRI, magnetic resonance imaging; CTA, computed tomography angiography; US, ultrasound; CHF, congenital hepatic fibrosis; NICH, Noninvoluting congenital hemangioma.