New Vascular Malformation Clinic a Resource for Children With Vascular Birthmarks and Complex Vascular Anomalies

from Practice Update, Spring 2004

Team members pictured: (l to r) Peggy Kelley, MD,
Taru Hays, MD, Joseph Morelli, MD, John Schilz, Clinic
Administrator Lawrence Ketch, MD

Vascular birthmarks are very common. Many require no treatment. However, the anomaly can range from a simple skin discoloration to large devastating malformations that may require the coordination of both medical and surgical specialists to treat. Some vascular malformations may require interventions, such as laser therapy or embolization for cosmetic reasons. If the lesion is complex, if there is ulceration or bleeding present, or if there is involvement of the underlying soft tissues or internal organs, numerous specialists may be required for the best treatment outcome.

The most common vascular anomalies are hemangiomas, composed of proliferating capillaries. These are in up to 10 percent of infants and tend to occur on the head and neck. They occur two to three times more common in females than males. Hemangiomas can be superficial, subcutaneous or mixed. They generally proliferate in the first year, then slowly involute over an average of five years. All will regress and many will not require treatment. However, complex cases can cause scarring and distortion of facial features and, in the most severe cases, can be life threatening.

Vascular and lymphatic malformations are less common. They affect girls and boys equally. There is no proliferation of vessels, but a progressive dilation of capillaries, veins, lymphatics and/or arteries. There is no regression stage and improvement occurs with intervention.

The Treatment Team

An interdisciplinary team has been formed to evaluate and treat vascular anomalies in children. The team includes specialists from Otolaryngology, Plastic Surgery, Dermatology, Hematology, Pediatric General Surgery and Interventional Radiology. Under the leadership of Peggy Kelley, MD, a specialist in otolaryngology, and Lawrence Ketch, MD, chairman of Plastic and Reconstructive Surgery, the team holds monthly clinics for interdisciplinary evaluation of young patients. Core team members include Drs. Peggy Kelley, Larry Ketch, Joseph Morelli, Taru Hays, Fritz Karrer and Roger Harned. John Schilz, the clinic administrator, has been recruited to organize the clinic, obtain referrals and coordinate treatment plans outlined by the physicians. Additionally, consultative services are available from the broad range of pediatric specialties at the hospital.

Dr. Kelley explains why the team answers a demand for a regional center, “Vascular malformations and hermangiomas are undiagnosed or misdiagnosed in over half the cases. More common in low birth weight premature infants, these non-cancerous lesions can cause significant circulatory stress depending on their size or location and, in the most serious cases, can be life-threatening. With the development of a vascular malformation clinic at The Children’s Hospital, our team of pediatric specialists can identify those cases that need only observation and counseling and those with a more serious pathology. Effective long-term treatment of both simple and complex lesions depends on a partnership of specialists, the child’s primary care provider and the parent/s. Having an evaluation and treatment center here in Denver puts less distance into the equation. Families and PCPs now have local expertise in the management and treatment of these anomalies.”

Magnetic resonance imaging, computed tomography, ultrasonography and angiogram supplement the team’s experienced diagnostic abilities. While simple lesions can often be diagnosed through physical examination, the extent of more complex lesions often requires advanced imaging techniques. When children need to be consciously sedated or anesthetized to perform diagnostic tests, pediatric anesthesiologists, trained specifically in the delicate science of administering anesthesia to infants and children, join the treatment team.

Slow flow malformations can often be treated with observation and supportive treatments such as compression garments or drug therapy. Laser therapy is also an option for superficial lesions. The management of deep or combined vascular lesions is far more complex. High-flow malformations often require surgical excision or embolization. A full team of surgeons is available, if excision and consequent reconstructive surgery is indicated, and can rely on Dr. Ketch, one of the preeminent pediatric plastic and reconstructive surgeons in the country. He has over 20 years experience with these malformations. Dr. Ketch says, “Most clinicians will see only a few life-threatening or exsanguinating hemorrhagic vascular malformations in a lifetime of practice. Interventionalists with significant knowledge and skill are needed to treat these anomalies even in the treatment of less severe lesions with alcohol sclerotherapy. By bringing together an experienced multidiscip-linary team of pediatric specialists, including radiologists and pediatric nurses, we offer the best results in both simple and complex cases in the region.”

“Families and PCPs now have local expertise in the management andtreatment of these anomalies.”   
– Peggy Kelley , MD , Co-Director, Vascular Malformation Clinic

The consolidation of medical and surgical expertise in a dedicated clinic for vascular malformation extends treatment options for the region’s children. From simple asymptomatic birthmarks to complex lesions, treatment can be accomplished without long-distance trips to far clinics. Specialists and primary care givers can collaborate in treatment that is family-centered and convenient.

For a consultation concerning a child with a vascular malformation, call One Call at 800-525-4871 or 720-777-3999.

Types of Vascular Malformations

Capillary Malformations (Portwine Stains)

Enlarged diameter of capillaries results in a flat, defined vascular stain. Presents with a pink to deep purple appearance. Most common in the head and neck region. A malformation on the eyelid can result in intraorbital pressure and impaired vision.

Lymphatic Malformations

Abnormal channels and spaces within the lymphatic system usually presenting as swelling in the affected area through the accumulation of fluid. Extensive enlargement of soft tissues and bones can occur.

Venous Malformations

Superficial or deep veins that are abnormally formed or dilated. They can be asymptomatic for years or show a slow, steady enlargement. Areas commonly affected include the tongue, cheek or jaw.

Arteriovenous Malformations

Direct connecting of veins and arteries in the absence of a capillary bed. Can appear as a “blush” that becomes dark red or purple as the child grows. A firm mass often develops beneath the stain.

Combined Vascular Malformations

Involve two or more types of vessel abnormalities. May involve overgrowth of soft tissues and bones, pain, skin breakdown and, in severe cases, congestive heart failure.