Following full diagnosis of type, location and extent of a vascular abnormality, the most suitable management and treatment options can be discussed. There is no one gold-standard treatment scheme for this diverse group of conditions, including haemangioma and vascular malformations. Typically, several options need to be considered. Broadly speaking, vascular malformations are more likely to require treatment than haemangioma.
Treatment options include a conservative watch & wait approach, surgical interventions of variable degrees of invasiveness, including laser treatments, and a range of medical treatment schemes (sclerotherapy).
In the majority of cases, a haemangioma does not require any treatment other than management by ‘watch and wait’ until the lesion resolves by itself, typically around nine years of age, by when 90 % of these lesions will have resolved. Interventions are only necessary if the lesion is prone to ulceration and/or bleeding, and/or becomes infected, or if in the proliferation (growth) phase of the haemangioma vital functions (in particular the airway, swallowing, or the optic nerve) are impacted. Very large haemangioma may also warrant early intervention to prevent extensive lasting scarring, lasting impaired functionality, or even congestive heart failure from extremely massive lesions. There are surgical as well as medication-based options for treatment, with a range of medicinal drugs used to shrink the lesion, sclerotherapy (steroids and propranolol). It is estimated that over the ‘life cycle’ of a haemangioma, in about 25 % of cases at some stage some form of intervention is required, most commonly to address ulceration.
The treatment options for the management of vascular malformations vary for the different types and extent of these lesions.
The treatment schemes for venous malformations range from conservative wait & watch approaches for small and asymptomatic lesions, to a number of sclerotherapy options, to surgical excisions, to combinations of treatment modalities. Interventions are indicated where venous malformations cause pain, disfigurement, haemorrhage (severe bleeding), increased risk of thrombosis, or impact neighbouring structures and their function, such as the airway or optic nerve. Treatment decisions for venous malformations are usually guided by location and extent of the lesion(s).
A similar overall picture holds for the treatment modalities for lymphatic malformations, including conservative monitoring schemes, sclerotherapy, and/or surgical interventions. Sclerosing agents used in the treatment of lymphatic malformations may differ from those most commonly used to treat venous malformations. Similarly, there may be some differences in the choice of medicinal drugs used in a conservative monitoring approach. Choice of the most suitable treatment modalities of lymphatic malformations not only depends on location and extent of the lesion(s), but also on their type and characteristics. Singular (macrocystic) lesions tend to be easier to treat by surgical excision and/or sclerotherapy than multiple distributed minor (microcystic) lesions; the latter may require repeated treatments.
Depending on location and extent of the lesions, the treatment of arteriovenous malformations by combined sclerotherapy or rather embolization, and surgical interventions can be challenging. Surgical resection after sclerotherapy is most promising for smaller and localised such lesions. Large arteriovenous malformations may also require surgical interventions, especially with progressive and invasive behaviour of the lesion and/or in the presence of potentially life-threatening haemorrhage (bleeding). Extensive resection of such lesions may require reconstruction with free flaps and/or other vascular surgery interventions. Curative treatment of arteriovenous malformations by complete resection is not always possible, repeated sclerotherapy interventions of any residual lesions may be necessary postoperatively. Recurrences are common after treatment of arteriovenous malformations.
Next section: Vascular abnormalities