MR-guided percutaneous sclerotherapy of low-flow vascular malformations: Clinical experience using a 1.5 tesla MR system

Abstract

Purpose: To demonstrate the feasibility, safety, and effectiveness of image-guided sclerotherapy of low-flow vascular malformations using a 1.5 Tesla (T) MR scanner with real-time imaging capability and in-suite fluoroscopy.

Materials and methods: Thirty-three procedures were performed with real-time 1.5T MR-guidance on 22 patients with a vascular malformation in the neck (n = 2), chest (n = 6), abdomen and pelvis (n = 15), and extremities (n = 11). Quantitative analysis was performed for changes in (a) planning time, (b) targeting time (interval between needle skin puncture and lesion access), (c) intervention time (interval between needle skin puncture and needle removal), and (d) total procedure time. Qualitative analysis was performed for (a) success of therapy and (b) occurrence of complications.

Results: Technical success was achieved in 29 of 33 procedures. The average planning time did not significantly change between the first seven procedures and the last seven procedures (P = 0.447). The average targeting time decreased by 0:24:45 (hours:minutes:seconds) (P = 0.043), the average intervention time decreased by 0:26:58 (P = 0.022), and the average procedure time decreased by 0:28:41 (P = 0.046) when comparing the first seven procedures and the last seven procedures. Overall, there was an improvement in the patients' predominant symptoms following 82% of procedures, including a significant decrease in average pain following therapy (P < 0.001). There was a minor complication rate of 3% with no major complications.

Conclusion: MR-guided percutaneous sclerotherapy seems to be a safe, effective, and versatile technique for treating low-flow vascular malformations.

Level of evidence: 3 J. Magn. Reson. Imaging 2017;45:1154-1162.

Keywords: lymphatic malformations; sclerotherapy; venous malformations.

Figure 1

Methods Flowchart. a: Workflow #1 was completed with MR imaging alone; “Milder” sclerosants including Doxy, EO, and STS, as well as smaller volumes of ETOH are delivered with real-time MR guidance. b: Workflow #2 utilized the in-suite fluoroscopy, which allowed for the safe delivery of larger volumes of ETOH.

Figure 2

Treatment of 41-year-old woman with Klippel–Trénaunay Syndrome. a: Pre-treatment axial T2 TSE with fat saturation demonstrating a massive intraabdominal VM. b: Scanner setup showing interventional radiologist placing needles under direct MR-guidance using the IFE projected onto a screen in the scanner room. c: Axial RT TrueFISP image showing multiple needles (yellow arrows) placed in deep lesions, avoiding critical structures such as the Aorta and Vena Cava (red arrows). d: Post-treatment axial 3D VIBE confirming delivery of gadolinium-doped sotradecol within multiple portions of the VM. Two of the treatment needles can also be seen (yellow oval).

Figure 3

20-year-old woman with Blue Rubber Bleb Nevus Syndrome. a: Pre-treatment axial T2 SPAIR with fat saturation demonstrating septated VM (arrow) within the right psoas muscle. b: Needle targeting VM (arrow) with sagittal RT TrueFISP. c: Flow assessment within the lesion (arrow) with axial subtracted FLASH. d: AP planar projection during administration of sclerosant (100% ETOH, arrow) using fluoroscopy. A 19 cm loop coil used for MR-guided needle placement can be seen. e: Axial T1 VIBE of VM (arrow) 10 minutes after treatment showing thrombus within the lesion. f: Axial T2 TSE with fat saturation of healed VM site (arrow) 6 weeks post-treatment.