Percutaneous photocoagulation of deep vascular lesions using a fiberoptic laser wand.

A new technique is presented for the treatment of deep vascular lesions. A potassium-titanyl-phosphate (KTP), argon, or Nd:YAG laser is attached to a fiberoptic wand, which is passed percutaneously. The laser is activated and coagulates the lesion without direct injury to the skin. Eleven hemangiomas and two lymphangiomas have been treated using this technique. A reduction in size of the lesions was obtained in all patients. Repeat treatments were done to improve results in six patients. Conventional transcutaneous laser therapy was used as an adjunct in four patients. Average patient follow-up was 29 months. No major complications have been noted in this series. Percutaneous fiberoptic photocoagulation has been found to be a safe, long-lasting technique for the treatment of deep vascular lesions.     

Treatment of cutaneous and deep vascular lesions with the Nd:YAG laser

This study intends to document and evaluate the first compiled experience in the treatment of both cutaneous and deep vascular lesions using the Nd:YAG laser. Thirty-eight patients were treated over a 5-year period from 1979 to 1984 using the Nd:YAG laser with FDA approval. Lesions included capillary, cavernous, combined capillary-cavernous hemangiomas, portwine stains, arteriovenous malformations, lymphangiomas, multiple telangiectasias, and one case of Klippel-Trenaunay-Webber syndrome. The number of treatments per patient ranged from one to four. Partial or complete resolution of these various lesions, as evidenced by a decrease in size, and/or normalization of pathologic cutaneous changes was noted in a majority of patients. While both the argon and CO2 lasers have been well studied in the treatment of cutaneous vascular lesions, this is the first compiled series reporting results using the Nd:YAG for such problems. The Nd:YAG laser represents an alternative modality in the treatment of cutaneous hemangiomas and introduces an efficacious method in the treatment of cavernous vascular lesions.     

Reduction of pain in the treatment of vascular lesions with a pulsed dye laser and pneumatic skin flattening

The treatment of vascular lesions, including port wine stains (PWSs), with a pulsed dye laser is very painful and often requires general anaesthesia. This is particularly problematic with children. Pneumatic skin flattening (PSF) is a new technology that naturally reduces pain in laser-based aesthetic treatments. The objective of this study was to test pain reduction, as well as lesional clearance, by combining pneumatic skin flattening (PSF) technology with a pulsed dye laser in the treatment of vascular lesions. Twenty-one patients (three of them children) were treated for vascular lesions, mostly PWSs (13 patients). The patients were treated with a 595 nm pulsed dye laser operated at energies of 5.75–13.25 (median 9.25) J/cm². Acute pain was evaluated in all 21 patients. Topical anaesthetic (EMLA cream) was applied before treatment in six cases. Identical energies were applied to both sites. The pain during PSF treatment was compared to pain during regular treatment without PSF. Blanching response to treatment was evaluated in 18 patients after 6–12 weeks. Significant pain reduction was observed in 21/21 patients (100%). The average reduction in pain score was from 10 without PSF (painful) to 2.6 with PSF (comfortable). Follow-up examination of 18 patients after 6–12 weeks showed identical blanching of tissue in both the PSF-treated areas and those not treated with PSF in all patients. It was concluded that the PSF technology significantly reduced pain in the treatment of vascular lesions with a pulsed dye laser without affecting efficacy.     

Management of congenital arteriovenous malformations

Twenty-five patients with congenital arteriovenous malformations (AVMs) involving the head, neck, trunk, or extremities were treated over a 10-year period. In patients with more extensive lesions, selective angiography was essential to delineate the extent of the AVM and its vascular anatomy. AVMs that produced congestive heart failure, hemorrhage, pain, or cosmetic embarrassment were excised if possible. Intra-arterial embolization is useful in the reduction of vascularity before operation or as the primary treatment for unresectable lesions. Incomplete excision or embolization of the AVM often results in a recurrence. However, nonsymptomatic lesions may be observed, and extremity varicosities can be treated by external compression.     

The pathology of head and neck tumors: Vasoformative tumors,part 9A

Tumors originating from components of the vascular system vary widely in the degree of morbidity and mortality that they incur. They all have endothelial cells as integral components of their histologic appearance. Vasoformative tumors include hemangiomas, lymphangiomas, and pyogenic granulomas, which are relatively common, and hemangiopericytomas, glomus tumors, and angiosarcomas, which are relatively uncommon. For many vasoformative tumors, including lymphogenous lesions, the head and neck is an area of predilection, and, in some instances, location in the head and neck appears to modify biologic activity.     

Progress report on extended clinical use of the argon laser for cutaneous lesions

Since 1970 a variety of cutaneous lesions have been successfully treated with the argon laser and the histopathology carefully studied at the Palo Alto Medical Clinic. Patients with port wine hemangiomas, capillary/cavernous hemangiomas, and telangiectasia have achieved successful resolution in some cases, and subtotal blanching in other cases, with a low incidence of scarring or other complications. Recently, decorative tattoos as well as a variety of miscellaneous pigmented or vascular skin lesions, such as seborrheic keratoses, pyogenic granulomas, and senile angiomas, have also been successfully treated with the argon laser. Total clinical experience is updated in this report.     

Outcomes of 532 nm Frequency-Doubled Nd:YAG Laser Use in the Treatment of Port-Wine Stains

BACKGROUND: Port-wine stains (PWSs) are congenital dermal malformations involving venules, capillaries, and, probably, perivascular nerves. The primary morbidities of PWS are psychological disturbances that adversely affect the development of personality. Lasers have been the treatment of choice for PWS. However, only one type of laser is not a panacea for all PWS malformations. For the treatment of PWSs, carbon dioxide, argon, krypton, copper bromide, frequency-doubled neodymium:yttrium-aluminum-garnet (Nd:YAG), flashlamp pumped pulsed dye laser, and also intense pulsed light sources can be used. OBJECTIVE: To determine the efficacy and the frequency of side effects of the frequency-doubled Nd:YAG laser for the treatment of PWSs. PATIENTS AND METHODS: In this study, 532 nm frequency-doubled Nd:YAG laser with a 2 to 6 mm spot size, 15- to 50-millisecond pulse width, and a 9.5 to 20 J/cm2 fluence was applied for 89 patients (62 female, 27 male; age range 3-49 years) with PWSs on the face and/or neck for 1 to 12 sessions, with 2-month treatment-free intervals. Improvement rates were considered a failure (< 25%), mild (25-49%), moderate (50-74%), good (75-94%), and excellent (> 95%). RESULTS: Excellent (n = 12; 13%), good (n = 34; 38%), moderate (n = 39; 44%), and mild (n = 4; 5%) improvement of lesions was obtained after an average of 5.6, 5.5, 4.4, and 3.8 therapy sessions, respectively. No treatment failure was observed for any patient. As adverse effects, transient hyperpigmentation (n = 2; 2.25%), hypopigmentation (n = 1; 1.12%), and hypotrophic scarring (n = 1; 1.12%) were noted. CONCLUSIONS: The results obtained asserted that the frequency-doubled Nd:YAG laser is a quick, safe, and effective treatment modality for PWS malformations and can be appreciated as a useful alternative therapy that can raise the rates of success in cases with PWSs refractory to other laser therapies.     

The use of the carbon dioxide laser in head and neck lymphangioma

The carbon dioxide laser has been used to treat various lesions of the head and neck, ranging from carcinomas to hemangiomas, and even including tatoos. A search of the literature does not reveal any reports of the carbon dioxide laser being used to treat lymphangioma. This report discusses the efficacy of treating lymphangioma of the air and food passages with the carbon dioxide laser, and presents three patients who have been treated in this fashion-two for palliation and one for cure.     

Treatment of pigmented skin lesions with argon laser irradiation

The article gives an account of material concerning treatment of 60 patients with pigmented lesions of the skin (capillary hemangiomas, pigmented nevus, tattoos) by exposure to argon laser radiation. The optimal regimens and doses of laser radiation for discoloration of pigmented skin lesions are stated. Methodological recommendations for applying three methods fo laser treatment of extensive capillary hemangiomas are suggested. The method used by the authors for treating pigmented skin lesions produced good and satisfactory cosmetic results in 95% of cases.     

Endoscopic laser therapy of the watermelon stomach.

Endoscopic laser therapy has been used in the treatment of vascular lesions throughout the gastrointestinal tract. The "watermelon stomach" is a pattern of vascular ectasia in the gastric antrum that results in chronic gastrointestinal blood loss and iron deficiency anemia. We have treated 7 transfusion dependent patients with a watermelon stomach using endoscopic laser therapy. Four of these patients were treated with the argon laser and 3 with the Nd:YAG laser. Patient age and prior transfusion requirements were similar in both groups. The mean number of treatments to obliterate vascular lesions and eliminate the need for transfusions was 5.75 +/- 0.89 (SEM) for the argon laser and 2.33 +/- 0.27 for the Nd:YAG laser (P < 0.05). Lesions recurred and required retreatment in 1 patient treated with the Nd:YAG laser and 3 patients treated with the argon laser (mean follow-up of 35 months). We conclude that endoscopic laser therapy with either the argon or Nd:YAG laser is an effective treatment modality for antral vascular ectasia (watermelon stomach). The Nd:YAG laser requires fewer treatment sessions than the argon laser to obliterate the lesions without increased risk of complications.     

Argon laser treatment of superficial vascular lesions in children

The author's experience in the use of the argon laser in the treatment of superficial vascular lesions in children is reviewed. Deteriorating portwine stains, strawberry hemangiomas, other hemangiomas, telangiectasias, and other lesions are discussed. Their natural histories are discussed. Details are given regarding indications for therapy, techniques, and postoperative results.     

Management of macular puckers associated with retinal angiomas

Monocular visual loss in four patients was caused by epiretinal macular membranes associated with peripheral retinal capillary angiomas or angioma-like lesions. Three patients had solitary vascular lesions and one had two discrete vascular lesions. All patients were in good health, with no evidence of the von Hippel-Lindau syndrome. In three patients, spontaneous peeling of the macular membranes and visual improvement occurred 2 to 6 months after obliteration of the angioma-like lesions with cryotherapy (two patients), or cryotherapy combined with argon laser (one patient). The fourth patient underwent a vitrectomy 8 months after the macular pucker had failed to respond to treatment of the vascular lesion.     

Treatment of vascular lesions with a CW yellow dye laser--initial trials

Thirteen patients with vascular lesions were treated with a CW yellow dye laser. Most of these patients were either poor candidates for argon laser treatment (ALT) or had undergone unsuccessful argon laser treatment. Twelve patients responded with a "desirable" treatment result. One patient did not respond adequately to have his result classified as "desirable," though all patients experienced fading of their lesions. None of the patients experienced scarring, epidermal thinning, or hypopigmentation. This lack of complications, associated with an incidence of desirable results in twelve of the thirteen patients, is noteworthy because all but one of the patients with portwine stain had difficult-to-treat lesions whose treatment is not attempted by many ALT centers. We believe that yellow light has certain advantages over blue-green argon laser light for the treatment of vascular lesions and think that further study is warranted.     

Large port-wine stains: Continuous argon laser treatment with neuroleptanalgesia

An original technique is presented for the treatment of large port-wine stains (PWSs) extending over several skin areas using the argon laser on continuous modelwith the patient under neuroleptanalgesia. Sufficient experience of this technique, used since August 1983, has now been gained to affirm that it is totally innocuous and has definite advantages. Small port-wine stains are still treated using a classic ambulatory method (1,3), while PWSs with a surface area greater than 35 cm² are treated by our technique. The technique and results are detailed and the advantages and disadvantages are discussed, based on a study carried out in Lille on the effects on tissue of continuous irradiation with a power output of 3 to 5 W.     

Surgical treatment for congenital arteriovenous malformation: 10 years' experience.

OBJECTIVES: We report our 10 years experience of the surgical treatment of congenital arteriovenous malformation (AVM). METHODS: We retrospectively reviewed the medical records of 145 patients with AVM who visited Samsung Medical Center in Korea from 1994 to 2003. Among the 145 patients, 21 patients were operated on. Preoperative embolo/sclerotherapy was done in 20 out of the 21 patients. RESULTS: The surgically treated AVMs were 13 cases of head and neck lesions, four cases of upper extremity lesions, one case each of back lesion, uterus lesion, lower extremity lesion and multiple site lesions. There were 10 patients with the extratruncular infiltrating type, nine patients with the extratruncular limited type, one patient with a truncular superficial AV fistula and one patient with a mixed type. Fourteen cases were operated on for cosmetic reasons and since they had localized lesions, and five cases were operated on for tissue necrosis. Fourteen cases were cured by a single operation, yet seven cases needed several sessions of operation to cure the AVM or to promote wound healing after surgery. CONCLUSION: The surgical treatment of AVM is a challenging issue for vascular surgeons. To minimise the complications related to surgery, a multidisciplinary team approach should be considered.     

Response of vascular lesions of the head and neck to argon laser radiation

Argon laser radiation is used to treat congenital and acquired vascular lesions of the head and neck. Thirteen patients requiring a total of 36 treatments were followed up for a minimum of 1 year to assess the response of the vascular lesion to argon ion radiation. Of the 13 patients, 10 had an excellent result, with the lesion no longer being identifiable. Three of the patients had residual but minimal color remaining in the lesion. There were no complications or hypertrophic scars after 1 year of follow-up. The laser parameters used and the surgical technique followed are outlined.     

Nd-YAG laser treatment of venous malformations of the head and neck: an update.

Malformations of the arterial and venous systems often are manifested in the head and neck. Low-flow venous malformations are generally benign lesions; however, complications, such as bleeding, obstruction, pain, or cosmetic deformities, may warrant surgical intervention. Treatment of these lesions can be challenging. Laser photocoagulation, particularly with the neodymium-yttrium aluminum garnet (Nd-YAG) laser, has been successful in the majority of patients, with minimal morbidity and good results. Thirty-two patients with low-flow venous malformations of the head and neck were treated with the Nd-YAG laser using low-power density and intermittent short exposures in a punctate nonoverlapping technique. When possible, two glass slides were used to compress the lesion. There was excellent regression with minimal damage to the surrounding tissue. No major complications or morbidity, postoperative pain, or mortality occurred. Lesions occurring in some areas of the head and neck would not have been amenable to standard surgical excision. Follow-up period has ranged from 1 to 8 years. Nd-YAG laser photocoagulation has proved safe and effective for treatment of low-flow vascular malformations of the head and neck.     

Intralesional corticosteroid therapy in proliferating head and neck hemangiomas: a review of 155 cases

PURPOSE: The purpose of this paper is to review the effect of intralesional corticosteroid therapy in the treatment of 155 head and neck hemangiomas. METHODS: In the past 10 years, we have treated 155 proliferating head and neck hemangiomas with intralesional corticosteroid injections. Three to 6 injections of triamcinolone acetonide (10 mg/mL) in monthly intervals were given. Using slides and chart review, the results were assessed 1 month after completion of the treatment. RESULTS: Eighty-five percent of the lesions showed greater than 50% reduction in volume. Varied treatment response was noted in different classes of hemangioma. Eighty percent of the superficial, 75% of the deep, and 60% of the combined hemangiomas show more than 50% reduction in volume. Further growth was not found after treatment. The postinjection complication rate was 6.4% in this series. There were 2 patients with cushingoid appearance, 5 with cutaneous atrophy, and 3 suffered from anaphylactic shock. We found that lesions showing less than 50% reduction in volume were located mostly in the perioral area. CONCLUSIONS: Intralesional corticosteroid injections are safe and effective in arresting hemangioma proliferation. Superficial hemangiomas yield the best results.     

A series of vascular tumors and tumorlike lesions of the bladder

Vascular tumors of the bladder are rare and a subject of small series and case reports. We retrospectively identified vascular tumors of the urinary bladder from the consultation files from one of the authors. We identified 13 lesions that included 3 hemangiomas, 3 intravascular papillary endothelial hyperplasias (Masson vegetant hemangioendotheliomas), 2 arteriovenous malformations (AVMs), 1 epithelioid hemangioendothelioma (EHE), and 4 angiosarcomas. One of the angiosarcomas was associated with conventional high-grade urothelial carcinoma (sarcomatoid carcinoma). All patients were adults with a range in age from 18 to 85 years old (mean 63.3). There was no statistical difference among the various lesions in terms of age, although angiosarcomas tended to arise in older patients (mean 71 y vs. 60 y of the remainder). Hematuria was the most common presentation of both benign and malignant lesions. Other symptoms included voiding irritation, pelvic pain, and obstruction. Histologically, benign and malignant lesions were similar to their counterparts in other organ systems. Two hemangiomas were of the capillary type and a third one of the cavernous subtype. They measured 1.1, 2.4, and 3.2 cm. Both AVMs were clinically large broad-based masses measuring 5.5 and 5.8 cm in greatest diameter. One of the AVMs was associated with pseudoepitheliomatous hyperplasia of the urothelium. All 3 patients with Masson lesion had history of radiation therapy for other causes. These presented as raised lesions and were all <1.0 cm. Patients with hemangiomas, papillary endothelial hyperplasias, and AVM had an invariably benign prognosis and needed no further therapy. These benign lesions had consistent involvement of the submucosa and spared the muscularis propria of the organ. All cases of angiosarcoma and EHE involved the muscularis propria. Two of four patients with angiosarcoma had a history of prior radiation therapy and all 4 were dead of disease at 6 months. Angiosarcomas measured 3, 4.5, 5, and 5.8 cm in greatest diameter at cystoscopy. The patient with EHE had a single nodule treated by transurethral resection of the bladder and no evidence of disease at 4 years of follow-up. None of the patients experienced marked gross hematuria that resulted in morbidity or mortality. A wide spectrum of benign, intermediate malignant, and malignant vascular lesions primarily involved the bladder. Despite the potential for marked hemorrhage, none of the tumors resulted in marked hematuria. Papillary endothelial hyperplasia occurs in the bladder and must be differentiated from angiosarcoma, which has a rapidly fatal outcome.     

Imaging of vascular lesions of the head and neck

The imaging armamentarium for imaging head and neck vascular lesions and the imaging features of each have been reviewed. Imaging is an indispensable part of the diagnosis and treatment planning of these lesions. The architecture and vascularity of these lesions are keys to their correct diagnosis. High-flow lesions (AVMs and hemangiomas) can be distinguished readily from low-flow lesions (venous malformations and lymphatic malformations) with these techniques, without the need for conventional angiography in the majority of cases. More-over, the architecture of the lesions depicted on imaging studies can lead to a reasonably specific diagnosis. MR imaging is the best tool for this assessment, but complementary information from ultrasound or CT can help arrive at the correct diagnosis when the results of MR imaging are equivocal. Ultrasound can correctly characterize the lesion as high flow or low flow but is limited in its ability to determine the full extent of the lesion. The usefulness of CT is more limited. Application of newer CT techniques (multidetector helical CT with image reconstruction) may increase the role of CT in high-flow lesions, but the greater soft tissue contrast sensitivity of MR imaging remains its strong suit. Conventional angiography is usually reserved for pretherapeutic evaluation.