范文一：动静脉吻合术

动静脉内瘘术

动静脉内瘘术是维持性血液透析患者常用的血管通路, 具有安全、 血流量充 分、感染机会少等优点。一般内瘘的使用可维持 4~5年。动静脉内瘘应选择非 优势侧手臂。因内瘘成熟一般约需 2~6周,故应提前手术,以备必需。静脉的 选择应较表浅,且分文少。

动静脉内瘘是维持性血液透析患者常用的血管通路,具有安全、血流量充分、 感染机会少等优点。一般内瘘的使用可维持 4~5年。

【内瘘的要求】

1.保证足够的血流量 (200~300ml/min)。

2.不影响患者的日常生活。

3.易于穿刺。

因此,动静脉内瘘应选择非优势侧手臂。因内瘘成熟一般约需 2~6周,故应提 前手术,以备必需。静脉的选择应较表浅,且分文少。

【常见内瘘术式】

1.腕部 桡动脉一头静脉、桡动脉一贵要静脉、尺动脉一贵要静脉和尺动脉一 头静脉;此外,还可以采用鼻咽窝内瘘。

2.肘部 肱动脉一头静脉、肱动脉一贵要静脉、肱动脉一 1月寸正中静脉。

3.其他部位 如踝部、大腿部内瘘、腋静脉内瘘等,很少采用。

常选用桡动脉与头静脉或做侧侧吻合或端端吻合或端侧吻合。 吻合可采用缝合法 和钛轮钉法。

【术中应注意】

1.尽量清理动、静脉血管游离端邻近的下分支及周围组织,以免牵扯致吻合口 成角,影响血流量。

2.尽量使动、静脉口径匹配,可采用修剪断端成斜面的方法。

3.尽量减少创面渗血,以免形成血肿压迫吻合口。

【术后护理】

1.抬高术肢,以利静脉回流,减轻水肿。

2.观察吻合口处震颤及杂音,检查内瘘是否通畅。

3.术肢勿测血压,穿刺及压迫。

4.使用时穿刺针应距吻合口 3cm 以上,静脉针与动脉针相距 5cm 以上。

5.尽量避免定点穿刺,以免形成假性动脉瘤及血栓,导致感染。

6.透析穿刺后压迫止血压力要适当,以免出血及血栓形成,阻塞内瘘。

【内瘘并发症】

1.血管狭窄 表现为低血流量,易发生在吻合口,尤其在距吻合口静脉端数厘 米内或反复穿刺的部位, 与手术操作不当或局部纤维增生有关。 早期发现后可行 血管气囊扩张术或腔内血管成形术, 有些弹性狭窄还可以放支架, 而国内大多直 接采用手术修复。

2. 血栓形成 手术中损伤血管内膜及使用过程中管腔狭窄导致血流缓慢而引起。 另外过度脱水及低血压, 不正确的穿刺方法导致局部出血也可诱发。 用多普勒超 声可准确测定血栓的部位。处理上可行经皮腔内血管成形术 (PTA)或血管内扩张 术、血管内溶栓术及用带气囊的导管或手术取栓。

3.静脉窃血综合征见于患者本身存在血管循环障碍,如全身性动脉硬化及糖尿 病患者。 其桡动脉与头静脉作侧一侧吻合时, 尺动脉血也可经掌动脉弓直接回流 到头静.脉,因此造成指端发冷、无力、麻木及疼痛以至坏死,检查时发现手背 浮肿或发绀。故应选择端端或端侧吻合,若做侧侧吻合,其吻合口应小于

8mm ,若术后发现患者指端疼痛等症状,则可将远端桡静脉结扎,缓解因静脉高 压造成的静脉回流障碍

若上述方式难于凑效,应直接结扎吻合口近心端头静脉,关闭内瘘。

4.肿胀手综合征 由于回流静脉被阻断或者动脉血流压力的影响,造成肢体远 端静脉回流障碍。 早期可以通过握拳增加回流, 减轻水肿, 长期肿胀必须重新制 作内瘘。

5.假性动脉瘤 主要由于内瘘使用时间过早及定点穿刺的后果。较小的动脉瘤 可用弹性绷带压迫,较大的则需手术可用 PTFE 血管做旁路搭桥手术或切除。 6.充血性心衰 系由于动静脉短路所致回心血量增加。一旦发生,可采用内瘘 包扎压迫或手术缩小瘘口。

7.感染较少见。化脓性伤口应行清创,引流及抗生素冲洗,如果血管发生感染 应将血管结扎。

范文二：动静脉转流式血管吻合术后血管危象60例观察与护理

动静脉转流式血管吻合术后血管危象60例

观察与护理 齐鲁护理杂志2008年第14卷第4期

血容量不足使心率加快.禁食期间补液量一般2000ml/d,前 ld3500ml左右,若发现胸腔引流量,胃肠减压量较多,口渴明 显,要及时提醒医师增加补液量,必要时输全血.补充血容量 的同时应注意补充电解质.术后常规补钾3,4g/d,定期查血 生化,根据结果调整电解质的补充量,维持循环血量及水电解 质平衡.

收稿日期:2007—10—10

动静脉转流式血管吻合术后血管危象

6O例观察与护理

国继霞

(新汶矿业集团中心医院山东泰安271221) 近年来,我院对60例患者成功采用动静脉转流式血管吻 合术进行组织移植,断指再植,足趾移植再造拇指,术后经严 密观察与精心护理,效果满意.现报告如下.

1临床资料

1.1一般资料本组60例,男38例,女22例,16,40岁. 拇指完全离断25例,中指完全离断20例,环指末节完全离断 4例.示,中,环,小指不完全离断2例,小指末节完全离断3 例,第2足趾移植再造拇指6例,术后组织成活,效果满意. 1.2典型病例患者男,20岁,因左手拇指外伤后缺损4个 月.要求行拇指再造.术前准备完毕,在臂丛麻醉+硬膜外麻 醉下行左第2足趾移植左拇指再造术,同时带有足背皮瓣. 术中见,第2足趾趾底动脉较细,直径约1mm,将足趾腓侧趾 动脉与趾底动脉穿支吻合,通血后移植足趾血运恢复缓慢.

术后2d发现动脉供血系统血循环危象,即刻在臂丛麻醉下行 血管探查术.并采用静脉动脉化,将桡动脉与大隐静脉吻合, 桡动脉伴行静脉与足背动脉的伴行静脉吻合,前臂浅静脉与 足背静脉吻合,通血后,远端血运恢复.术后抗炎,抗凝,扩血 管治疗.组织成活,住院22d出院.

2观察与护理

2.1心理护理显微外科是一门精细的外科学,患者的不良 情绪对病情起着明显的消极作用,如紧张,害怕,烦躁,忧郁等 心理因素.影响血管的收缩.尤其是断指再植术后,患者心理 因素有时会直接关系到再植患指的成活与否….术后出现血 管危象,患者心理负担重,担心手术失败,应做好心理护理. 关心,体贴患者,并向其讲解病情及手术过程,使患者增强战 胜疾病的信心,以积极的态度配合治疗与护理. 2.2病室要求术后病房室温应保持在25?.同时应用60 ,

100W烤灯持续照射患处,灯距25,30cm,一般照射7, 10d.病房内禁止吸烟,包括主动和被动吸烟,因香烟中的尼 古丁可引起毛细血管平滑肌痉挛使血管收缩,诱发血管危象 的发生.

2.3体位护理术后患者应绝对卧床休息2周,且保持平卧 位.将断指侧上肢抬高高于心脏.夜间应及时巡视病房,防止 患者夜间侧卧位压迫患指,影响肢体血液循环j. 2.4密切观察再造指血液循环术后应严密观察环指血液 循环,尤其是术后3d内是血管危象的高发期,再造指的皮肤, 颜色,温度及毛细血管充盈时间是观察血液循环的重要指标. 伤指应颜色红润,指腹饱满,湿润有弹性,甲床红白反应良好, 温度高于健指.如再造指颜色苍白,指腹萎缩发紫,静脉怒张

健指,动脉搏动微弱甚至消失等表示 甚至出现花斑,温度低于

血流障碍,血管危象存在,应及时通知医生处理.

2.5疼痛护理术后伤指疼痛给予镇痛处理,如哌替啶 100mg肌内注射,效果可靠,可避免疼痛,精神紧张引起的交感 神经兴奋使血管平滑肌痉挛,血管收缩j.

参考文献:

[1]段宝玲,马捷,孙巧慧,等.断指再植术后血管危象的分 析及护理[J].第四军医大学,2006,27(2):12—14. [2]聂娟.手术病人术后疼痛的护理进展[J].护士进修杂 志,1996,11(1):6—8.

[3]王燕.从断指再植术后发生血管危象原因谈夜间护理对 策[J].实用护理杂志,2000,16(1):27—29.

收稿日期:2007—12—28

自身骨髓血注射+'骨诱导生成蛋白微创治疗

胫骨骨折不愈合17例临床护理

李金萍

(潍坊市人民医院山东潍坊261041)

2006年1月,12月.我们采用自身骨髓血注射+骨诱导 生成蛋白(BMP)微创治疗胫骨骨折不愈合17例,并给予精心 护理,取得满意效果.现报告如下.

1资料与方法

112

1.1临床资料本组17例,男16例.女1例,23,62岁.胫 骨骨不连部位:胫骨上段骨不连13例,胫骨干骨折2例,桡骨 骨折2例.骨折对位线良好,均有钢板或外固定架固定,治疗 前x线片示:骨折线清晰,无骨痂生长.

范文三：血管吻合器和人工缝合建立动静脉内瘘对照分析

血管吻合器和人工缝合建立缝缝缝照静脉内

分析缝代缝床生物工程缝志医学学年第卷第期199842血管吻合器和人工缝合建立缝缝缝照分析静脉内

缝一缝缝勇一广刘——————

—

—————一

广医缝省梅缝人民院外科梅缝(514011缝缝缝血管吻合器缝缝人静脉内缝鼢当吁缝缝z.

中国号一R318.6Rr,"}i'j血液缝化缝法在我正缝于迅速缝展缝期国我.院自年月缝展血液透析缝法以共作缝来静19895

脉内缝例缝缝告如卞96..

缝床缝料1

一般缝料缝缝大部分缝慢性缝炎缝衰病人其中L196+男性倒女性倒缝用血臂吻合器咧人工缝合75+21.59.37

倒缝后透析效果良好占,99%.

缝式缝缝不缝是器械吻台或手工缝合均首缝缝缝脉1.2

和缝吻合静脉前者作端端吻台后者作端缝吻合缝化血脉+..管缝塞后改用尺缝或缝缝向上缝近通缝皮下缝移脉与静脉,

或移植相吻合静脉缝式不缝..

缝果2

血管吻合器吻合法缝点手缝早期吻台口2.1(1)

内膜不含缝缝水缝早期血流量高缝后小缝即...2

可穿刺透析解了人工缝合不能缝上使用的缺决,

点血管被吻合缝缝口限制内径径静脉不含充[1;(2),

盈缝度血流量缝定缝心缝影小响不缝生左心会+,,

衰操作缝缝快捷易缝缝床缝掌握医容易在:(3)..

基缝院推医广缺点血管口小于径者.(1)2.0mm无法用器械吻合血缝偏低者缝后充盈静脉;(2)

不充分且限制了血管的缝缝有造成手缺血的;(3)

可能.

人工缝合法缝点可作缝静脉缝缝端侵脉『2.2(1)/!吻台缝首缝的缝准缝式保留了缝缝的缝缝内脉

性当内需做尺例缝缝没有手缺血的危缝缝,,;(2)口缝小的血管能缝行吻合径缝后血管缝易缝;(3)

缝血流量大尤其适台血缝偏低的患者缺点...(1)操作比缝缝缝繁缝缝缝者的外科技缝操作要求缝.

高缝后,周才能使用;(2)23.

缝缝2

缝上所述吻台血管口大于径者缝首缝.2.0Tm器械吻台而血缝偏低或血管口小于径者,2.0mm缝缝人工缝合本院根据缝一原缝缝缝缝式在近,.

期取得良好的效果内但在缝床缝中到践体会此,,缝患者缝大部分需缝期透析极数弃少放治缝或行(

缝移植缝者静脉脉缝缝化后缝反缝穿刺及缝用高).

渗液刺激后逐缝硬化最缝缝塞大部分病人缝缝缝.

期血透需重缝作缝内器械吻台阻了缝缝缝缝性断脉..不可能用尺缝启脉再缝者需缝近或移植的将静脉,

静脉大缝或人造血管静脉通缝皮下遂道缝移至()

缝缝缝后容易造成迂曲静脉缝穿刺缝困缝来且,,,易缝致血栓形成同缝浪缝了尺缝部分缝端静脉..使手部血管未能得到充分利用从本文共倒缝.96后透析缝察中器械人工吻台均未缝生明缝的与并.

缝症依者的缝缝笔从近期效果看当缝缝器械吻.,.

台法从缝缝的缝点出缝仍需首缝人工缝合法缝宜..参献考文

高缝缝用缝制缝缝作缝成形缝静脉内痿中缝器官移1..植缝志『,1981.4.

来逢春于宗周血液缝化外缝学第版湖北科技学2,.,1.缝出版柱,1990,131

范文四：[doc] 动静脉转流式血管吻合的临床应用

动静脉转流式血管吻合的临床应用

动静脉转流式血管吻合的临床应用

生梁云碡’李月生’足.f

[内客提要]采用动静脉转沆的方法进行血管吻奇;共{了断脏r指’再瞳煦游离组螅砖随牝

l2倒,垒部获得成功.这种血循环重建方法可扩太断指再植的手术适应正,同时也却游离组纽移值

对’提

移植谚,/#/,【关键词:血管奶台断指再植.组织移植自睑,,ff?f,

自1983年以来.我们采用动静殊转流式

血管吻合的方法进行断指再植及组织{瞎移植

l2例,皆获成功报道如下

临床资料

本组l2例,男11例,女i倒.年龄l8,

36岁.拇指完全离断3侧.中脱套伤1例.

挤压1例.伴虎口区皮肤撕脱l例中指完

全离断4删,1阐为近节水平撕脱伤,3例为

中远节处斜形损伤.环指末节完全离断铡.

食,中指不完全离断伴掌刚皮肤血管严重缺

损各1例.右虎口区皮肤,左面桶部软组织陈

旧性缺损各l倒,缺损面积为4×5cm,

6cm.急诊手术lO例,择期手术2例术后均

获成功,功能恢复满意.

手术方法

1.静脉动脉化替代供血动脉缺损

1.i3倒拇指完全离断和l例中指撕

脱佑断指施行了指背静脉动脉比断指再植

术.断指均为严重外伤,指固有动脉干撕脱缺

损达网状分支处.指掌侧静脉挫伤,指背静脉

尚好,将其中一条与近端动脉吻台作为供血

动脉,另一条指背静脉与近端静眯吻合作为

回流,建立良好的血循环通路,晰指成活.

i.2前臂静脉网状皮瓣移植修复手指

不垒离断伴皮肤缺损2例,修复虎口部皮肤

缺损l制均成活.前者既螃复了皮肤缺损,叉

*山东薪泣矿务局中心医院外辩-27l柏3

行静脉移埴重建手指血循环皮稿?取Ij,f乜

含两条浅静弥干.顺血流方向响台.一条作为

『廿血动脉.另一条与指背静脉吻合运旭Z

后皮瓣稍肿,潮红,有散在小水癌.后自行消

散愈合后皮肤质地欠柔软.响包素0}.功

能恢复满意.

2.动静苴末吻合解决圆流静脉献损或

不足

动静脉吻爵替代斯指内回流静脉缺扳4

例.将断指内一条指动脉与近端动脉对端吻

合,通血后,另一指动脉即见适流血.将其与

近端静脉吻合构成循环.另1例皮瓣移埴路

复面颊部软组织缺损,静脉回漉不足,经动静

脉吻合而获成功

讨论

我们将奉自l12倒的血管吻合方式分为

两类,即静脉动脉化和动静脉吻合.统称为动

静脉转流式血管吻合其血液流变学特点在

于使传统的动弥一动脉,静脉一静脉吻方

法发生了转变.这种术式可扩大断指再值手

术适应证,提高再植成活率.也为组织瓣移植

时静脉回流不足的解决增添了一种新方法.

1.挤压撕睨性断指多伴有血管神经缺

损,处理非常困难,特别是脱套伤断指.以往

的再植术式成功机会很少.程国良”报道14

例中投育4例再植成功.这类断指的主要问

题是动脉损伤范厨广,破坏重.分点处往往宵

撕脱伤.无法进行血管吻合.

一

觯

一

镅

一

指背静脉动脉化可为此类断指再植成活

开辟一条新途径.这种方法是根据对手指血

管的解剖研究和动弥化静脉皮瓣移植成功的

启发下而设计的手指动静脉都在末节处

交汇,动脉与动脉,动脉与静脉网状交织成球

状.近节以远的指静脉无瓣膜,静脉动脉化血

液流经小静脉,动脉间的吻台支及细血管网

的返流到达动脉系统而营养组织实验和临

床研究还提示动脉和静脉都进行活跃的营养

交换活动,也为再埴成活提供了理论依据.

2.远侧指问关节附近的断指再植,动脉

吻合没有困难,但静脉往往较细,甚或无可供

吻合的静脉.在这类断指中,仅吻合动脉的成

活率较低,需用创面滴血等方法解决血液淤

滞问题.采用动静脉吻合手术,使回流静脉缺

损的断指有了回流的通路.我们还在游离

组织瓣移值静脉回流不畅时,大胆地采用了

动静脉吻合转流术式,使濒I瞄坏死的移植组

织得到挽救.

3.在实行动静脉转流式血管吻合时.囡

动静脉的管壁与管径均存在较大差别.对端

吻合时较为困难,我们应用了套迭缝合法”,

简化了手术方法.获得了可靠的通畅率.

参考文献amaY,so-S.FlapnourishedbyarTeHalinflaw

throughthe,0ussystem!nexperimental;nvestiga—

llon.pla~lR~onetrsI.1981l67}328

5冉春凌.喜绍奇.李纪录.啬小血管套选箍接珐及茸临床

应用.沂水医专1984;2:189

(收璃:1992—02—19悻回:1993—03一n8)

切开后埋线重睑成形术

钟圈群.

1989年4月,1991年5月,我科采用切开后埋

线重睦成形术共204恻.男7铡,女lg7倒年龄l3

,J8岁.行取嘲重睑术194倒.有侧单眼重硷术8

倒,左嘲单眼重睑术2倒.手术根据病人睑裂太小.

设计切口线.切开皮缺,翻转上睑.用一根带针s/o

尼龙线先在外眦端切口上唇皮下垂直进针,穿出睑

板.再从同一出针孔回针辫剌入与上唇进针点相距

3ram左右的切口下屠皮下出针,将上下唇两线头打

四Jf『省彭县血防医琬蕾璀美喜科.611930

结.剪去线头I在内毗端用同样方法以此类推,从两

边至中阿约缝线结扎6十结即可.最后在外眦部切

口内.于眶骨骨胰上缝合固定1针.观察皮肤是否对

齐,平整,有无眼裂睁不大或皮肤裂缝等.术后琦访

晟短1十月,最长25十月除2恻2十月同时切口娃

露出1线头,剪酴后无任何痕迹I1倒因过早提湿切

121,并发1十线头感染.剪去感染线头,局部废上霉

素液温教后愈合+重睑仍完荛无赢.余教果满意一

重睑线来消失.

(收稿ll991—03—11恬回:l991一{一l:1

范文五：动静脉瘘动静脉短路血管瘤

Direct percutaneous ethanol instillation for

treatment of venous malformation in the face and neck

Chih-Hsien Lee, Shyi-Gen Chen *

Division of Plastic and Reconstructive Surgery, Department of Surgery, National Defense Medical Center, Tri-Service General Hospital, No. 325, Section 2, Cheng-Gung Road, Taipei 100, Taiwan, ROC

Received 29April 2004; accepted 18April 2005

KEYWORDS

Ethanol;

Sclerotherapy;

Venous malformation

Summary Venous malformations of the face and neck involve multiple anatomical spaces and encase critical neuromuscular structures, making surgical treatment dif?cult; high recurrence rates and high morbidity are well documented. Various methods of treatment of uncertain value and risk of complications have been advocated. We present our experience in treating ?ve patients with venous malformation in the face and neck by using direct percutaneous ethanol sclerotherapy. Four patients had large lesions (R 3cm; one patient had two large lesions in the low eyelid), and the other had a mid-sized lesion (1.5–3cm). Under general or local anaesthesia, one-third to one-quarter cavity volume of ethanol was injected percutaneously, directly into the malformation with under ?uoroscopy [deLorimier AA. Sclerotherapy for venous malformations. J Pediatr Surg 1995; 30:188– 93; Johnson PL, Eckard DA, Brecheisen MA, Girod DA, Tsue TT. Percutaneous ethanol sclerotherapy of venous malformations of the tongue. Am J Neuroradiol 2002; 23:779–82; Pappas DC Jr, Persky MS, Berenstein A. Evaluation and treatment of head and neck venous vascular malformations. Ear Nose Throat J 1998; 77:914–22; Lee CH, Chen SG. Direct percutaneous ethanol sclerotherapy for treatment of a recurrent venous malformation in the periorbital region. ANZ J Surg . 2004; 74(12):1126–7. 1–4].Four patients required two injections. All patients had remission and alleviation of their symptoms, with no major complications. Direct percutaneous injection of absolute ethanol provides a simple and reliable alternative treatment for venous malformation in the face and neck.

q 2005The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.

Congenital vascular malformations exhibit an endo-thelial cell growth cycle that affects the veins, capillaries, or lymphatics. 1These malformations grow proportionately with age. 1,2,5,6Complete

British Journal of Plastic Surgery (2005)58,

1073–1078

S0007-1226/$-see front matter q 2005The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.04.014

*Corresponding author. Tel.:C 886287927195; fax:C 886287927194.

E-mail address:shyigen@ms26.hinet.net(S.-G.Chen).

surgical excision is seldom achieved in the past, because this usually leads to nerve damage, massive bleeding, and deformity if the lesion is extensive or located in the face and neck. Scler-otherapy is an alternative method of treatment, and direct percutaneous treatment with 95%etha-nol has proven effective and safe. 2,5In this report, we describe and discuss our experience in treat-ment of venous malformations using direct ethanol instillation under ?uoroscopic guidance.

Patients and methods

Between October 1998and June 2003, ?ve men with recalcitrant venous malformation in the face and neck were admitted to and treated at our university-based teaching hospital. The average age of the patients was 22years (range20–23years). Diagnosis was con?rmed by either a combination of history clinical presentations (Fig. 1), gross ana-tomical ?ndings, or selective external carotid angiography and magnetic resonance imaging (MRI)(Fig. 2). All patients had complete medical records available for retrospective review.

Percutaneous ethanol sclerotherapy was used under ?uoroscopy using intravenous general anaes-thesia. Rubber bands were used to compress the patient’s forehead and chin to occlude facial venous return. Contrast medium was injected toward the engorged vascular lesion using a No. 18 venipuncture catheter, followed by injection of one-third to one-quarter cavity volume of 95%ethyl alcohol into the tumour cavities under ?uoroscopic monitoring (Fig. 3).

Upon withdrawal of the catheter, compression was maintained for 5min to ?x the solution in the clot and the vein walls. A venous blood sample was taken at the end of the procedure to determine the serum ethanol level. Intravenous dexamethasone (0.1mg/kg)was given for 3days postoperatively to control in?ammation. This was then gradually tapered off over the following 5days.

Repeated courses of 95%ethanol injection were administered into very large malformations. Over-

all, the ?ve patients underwent eight sessions of ethanol sclerotherapy. The interval between injec-tions was usually 3–6weeks, to determine whether abnormal venous channels persisted. The patients were examined with MRI to evaluate the possible remaining extent of venous malformation. Treat-ment success was determined clinically by reduction in lesion size and by patient satisfaction. Results

Three malformations were located in the cheek, three in the eyelid—one patient had a combined lesion in the cheek and eyelid and the other had two lesions in the eyelid—and one in the posterior neck. All patients had some cosmetic manifestations. The number of injections ranged from one to two.

Three Figure 1(A)The clinical appearance of soft-tissue deformity situated around the patient’s right cheek. (B) The clinical appearance of a soft protruding mass situated around the patient’s left lower eyelid and left cheek. C.-H. Lee, S.-G. Chen

1074

patients had undergone previous surgical interven-tion. One had experienced functional dif?culty, with hearing disturbances after the ?rst surgical intervention. Direct intralesional contrast injection was performed under ?uoroscopy to demonstrate and determine the volume of venous cavities. Four patients had large lesions (R 3cm; one patient had two large lesions in the lower eyelid), and the other had a mid-sized lesion (1.5–3cm). All the patients had remission and alleviation of their symptoms, with no major complications. Four patients required two injections. Two patients had transient facial paresis, which resolved spontaneously within 3–5days (Table 1).

Follow-up ranged from 9to 62months (mean43.6months). The malformation size was reduced, and all patients expressed satisfaction with the result.

Case reports

Case 1

A 21-year-old man had a recurrent venous malfor-mation of the right cheek. Initial tumour excision surgery was performed at another hospital 14years ago. The symptoms were temporarily relieved, but gradually recurred. The venous malformation occu-pied the right cheek and cosmetic problems were noted (Fig. 1(A)).Percutaneous ethanol sclerother-apy instillation under ?uoroscopy was used in place of surgery. A total of 50mL of ultravist contrast medium (Berlex)was injected into the venous pouch of the right cheek using a No. 18venicath-eter, followed by 13mL of 95%ethanol. Post-operatively, hydrocortisone was given intravenously for 3days to diminish any in?amma-tory reactions. Near-complete obliteration of the venous malformation was achieved after two sets of injections (Fig. 4(A)).The patient is very satis?ed with the results, and there have been no compli-cations or recurrences during a 48-month follow up period.

Case 2

A 21-year-old man had two recurrent venous malformation of the left lower eyelid. Initial tumour excision surgery was performed at another hospital 10years ago. The symptoms were tempor-arily relieved, but gradually recurred. This venous malformation occupied the entire left orbital cavity and interfered with vision. Physically, his conjunc-tiva was in?amed and there was a soft tissue mass with local tenderness around his left lower eyelid and cheek after Valsalva’s manoeuvre (Fig. 1(B)).Visual acuity was 1.0(6/60),bilaterally and no visual ?eld defect was noted. Complete

surgical

Figure 2(A)T2-weighted magnetic resonance image showing an area of high signal intensity, which represents the low-?ow vascular malformation over the left maxillary region and the left infraorbital region

(arrow).

Figure 3Operative ?eld. Rubber bands were used to compress the patient’s forehead and chin to occlude facial venous return.

Ethanol instillation for venous malformation in the face and neck 1075

removal was not possible due to extensive involve-ment of the left orbital cavity and periorbital soft tissue. Percutaneous ethanol sclerotherapy instilla-tion under ?uoroscopy was, therefore, used. Two major venous malformations were treated, and percutaneous venograms using soluble contrast media were used to determine the volume of the growths before treatment. A total of 20mL of ultravist (contrastmedium was injected into the larger venous pouch using a No. 18angiocatheter, followed by 5mL of 95%ethanol. In the other venous pouch, 25mL of ultravist was injected,

Table 1Patient details Case No. Age

Location

Previous surgery Pre-operative size (ml)Injected number Complication

Post-operative size (ml)Follow up (month)121Cheek

Yes 502Mild pain 16482a 23Low eyelid Yes 252Mild pain

8623

20Cheek

Yes

72

1

Postoperative hearing

disturbance, transient facial paresis 8

9

423Low eyelid, cheek No 32Transient facial paresis 0.5495

23

Posterior neck

No

20

1

Mild pain

2

50

a

Two malformations were present in the eyelid of this

patient.

Figure 4(A)Near-complete obliteration of the venous malformation was achieved after two sets of injections were given. (B)Near-complete obliteration of the venous malformation was achieved after two sets of injections were given.

C.-H. Lee, S.-G. Chen

1076

followed by 8mL of 95%ethanol. Postoperatively, hydrocortisone was given intravenously for 3days to diminish any in?ammatory reactions. Near-complete obliteration of the venous malformation was achieved after these two sets of injections (Fig. 4(B)).The patient is very satis?ed with the results, and there have been no complications or recurrences during a 62-month follow up period. Discussion

Vascular malformations appear at birth as dys-morphic vessels. 7Depending on the predominant vasculature involved, they are classi?ed as arterial, capillary, lymphatic, venous, or combined. 1,3,4,7–9 Lesions may be localised, or can involve extensive areas of the body. Histologically, they comprise thin-walled channels, de?cient in smooth muscle, and lined by a single layer of endothelium. 1,2 With lesions in the face and neck, patient concern focuses on cosmetic considerations more than functional dif?culties. 3Symptoms vary depending on the location of the lesions, which are soft, compressible, nonpulsatile masses that may cause sudden pain, and which may exhibit development of a ?rm mass that subsides within days. 1,7Even small venous malformations can cause severe pain. Phleboliths are occasionally palpable and are con?rmed by radiography. 3Few venous malformations are radioresistant. 1The lack of prominent pulsation indicates they are not arter-iovenous malformations. They can be compressed to empty the blood contents, but the vascular channels become slowly distended as the com-pression is released. Venous malformations of the face and neck may be become more engorged during Valsalva’s manoeuvre or dependent positioning. 3

The diagnosis of venous malformations is based on careful history and clinical examination. MRI can be used to de?ne the extent of the malformations of the face and neck, and de?ne the pathway of venous drainage. 1,3,6,8Venous malformations show high signal intensity on enhanced MR images, 6,8 which can be used to de?ne the muscles or organs involved. The malformations are classi?ed as large (R 3cm); medium (1.5–3cm) and small (lessthan 1.5cm). 5The patients were examined with MRI after sclerotherapy, but the clinical signi?cance of postimaging is not so clear. 9

Venous malformations have been treated by a variety of techniques over the years, including irradiation, electrocoagulation, cryotherapy, intra-vascular magnesium or copper needles, surgical excision, lasers, compression, and sclerotherapy. 8, 10,11All these techniques have their particular indications and limitations. Surgical excision is useful only for localised and limited lesions. Aggressive excision can lead to signi?cant loss of motor function, cosmetic problems, nerve damage, or massive bleeding in patients with extensive involvement because of the complicated anatomy of the face and neck. 6,12Previous surgical treat-ment of one of our patients produced a hearing disturbance. Sclerotherapy has the advantage of no external scaring, and few complications in com-parison with surgical treatment. There are various choices of agents for sclerotherapy:5%sodium morrhuate, sodium tetradecyl sulphate, ethanola-mine oleate, OK432, bleomycin, ethanol, and hypertonic saline, alone or in various combinations, have all been used. 1,7,9,13–15There is no ideal vaso-occlusive substance applicable to all venous mal-formations. Bleomycin is an established antineo-plastic drug, very few studies in the past have made use of bleomycin as a sclerosing agent and showed higher incidence of residual disease. 14Ethanol shows the lowest rate of malformation recurrence and is the most reliable substance of all of the sclerosing agents. 3,9,12,16Ethanol is the most of often used due to its low cost, antiseptic quality, wide availability and easy of use; however, ethanol sclerotherapy requires general anaesthesia because the procedure is very painful. 13Direct percuta-neous contrast injection into the cavity is also required to detect the lesion volume and the possibility of multiple compartments.

The volume of ethanol to be injected is deter-mined from the percutaneous contrast study. In our patients, one-third to one-quarter of the cavity volume of 95%ethyl alcohol was injected into the tumour cavities. 1–4After injection, ethanol scler-otherapy requires stagnant ?ow and prolonged exposure to the endothelium to cause disruption of the endothelium, intense in?ammatory reac-tions, and blood coagulation. 1–3,13To achieve the required result and to minimise the ?ow of ethanol into normal venous drainage structures, we used rubber bands to compress the patients’ foreheads and chins to occlude facial venous return. Repeated aggressive treatment is required for very large malformations because recanalisation can occur, and to reduce the risk of major morbidity from the ethanol injection. 1,12Four of the ?ve sclerotherapy patients in this study had staged treatment, with multiple injections. The interval between injec-tions is usually 3–6weeks, to allow time to determine whether abnormal venous channels persist and to allow local reactions to subside.

Ethanol instillation for venous malformation in the face and neck 1077

Themaximum recommended dose of ethanol is 1mL/kgof body weight. 2,7,16,17

Patients were administered 0.1mg/kgof dexa-methasone immediately before the procedure, and then every 8h while in the hospital. Sclerotherapy has the potential to fail with inaccessible lesions, the lack of a proper vein for direct puncture, premature interruption of therapy, venous out?ow connected to the deep vein system, and the proximity of nerves surrounded by extensive venous malformation. 12,18Potential complications of scler-otherapy include local skin necrosis, transient nerve palsy, haemoglobinuria, blood loss, and anaphylaxis. 1,3,5,7,8,11–13,18Two patients in this study experienced transient facial nerve palsy, which resolved spontaneously within 3–5days. The major disadvantage of this treatment is severe complication can rarely occur and include acute pulmonary hypertension with cardio-pulmonary collapse. 13To avoid such a catastrophic situation, it is suggested to inject the ethanol slowly combined with rubber band compression. 9,13Absol-ute alcohol has not produced any reported allergic reactions; however, the injection volume must be limited because cerebral intoxication can occur with very small amounts. 1The reported compli-cation rates for percutaneous ethanol sclerother-apy range from 0to 15%.8In this study, all patients experienced symptomatic or cosmetic improve-ment without major complications.

Permanent obliteration of lesions using percuta-neous ethanol sclerotherapy is easier to achieve in small-diameter vessels, and thus, ethanol scler-otherapy is an effective alternative treatment for venous malformations of the head and neck, and it is wise to begin this treatment as early as possible once the diagnosis is made. Careful planning is essential to reduce the potential risks of the procedure, and long-term follow-up of patients is needed to detect any recurrence.

References

1. de Lorimier AA. Sclerotherapy for venous malformations. J Pediatr Surg 1995; 30:188–93.

2. Johnson PL, Eckard DA, Brecheisen MA, Girod DA, Tsue TT. Percutaneous ethanol sclerotherapy of venous malfor-mations of the tongue. Am J Neuroradiol 2002; 23:779–82.

3. Pappas Jr DC, Persky MS, Berenstein A. Evaluation and treatment of head and neck venous vascular malformations. Ear Nose Throat J 1998; 77:914–22.

4. Lee CH, Chen SG. Direct percutaneous ethanol sclerotherapy for treatment of a recurrent venous malformation in the periorbital region. ANZ J Surg 2004; 74(12):1126–7.

5. Siniluoto TM, Svendsen PA, Wikholm GM, Fogdestam I, Edstrom S. Percutaneous sclerotherapy of venous malfor-mations of the head and neck using sodium tetradecyl sulphate (sotradecol).Scand J Plast Reconstr Surg Hand Surg 1997; 31:145–50.

6. Yamaki T, Nozaki M, Sasaki K. Color duplex-guided scler-otherapy for the treatment of venous malformations. Dermatol Surg 2000; 26:323–8.

7. Berenguer B, Burrows PE, Zurakowski D, Mulliken JB. Sclerotherapy of craniofacial venous malformations:com-plications and results. Plast Reconstr Surg 1999; 104:1–11. 8. Lewin JS, Merkle EM, Duerk JL, Tarr RW. Low-?ow vascular malformations in the head and neck:safety and feasibility of MR imaging-guided percutaneous sclerotherapy—preliminary experience with 14procedures in three patients. Radiology 1999; 211:566–70.

9. Rautio R, Laranne J, Kahara V, Saarinen J, Keski-Nisula L. Long-term results and quality of life after endovascular treatment of venous malformations in the face and neck. Acta Radiol 2004; 45(7):738–45.

10. Ogawa Y, Inoue K. Electrothrombosis as a treatment of cirsoid angioma in the face and scalp and varicosis of the leg. Plast Reconstr Surg 1982; 70:310–7.

11. Li ZP. Therapeutic coagulation induced in cavernous hemangioma by use of percutaneous copper needles. Plast Reconstr Surg 1992; 89:613–22.

12. Lee BB, Kim DI, Huh S, Kim HH, Choo IW, Byun HS, et al. New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation. J Vasc Surg 2001; 33:764–72.

13. Rimon U, Garniek A, Galili Y, Golan G, Bensaid P, Morag B. Ethanol sclerotherapy of peripheral venous malformations. Eur J Radiol 2004; 52(3):283–7.

14. Mathur NN, Rana I, Bothra R, Dhawan R, Kathuria G, Pradhan T. Bleomycin sclerotherapy in congenital lymphatic and vascular malformations of head and neck. Int J Pediatr Otorhinolaryngol 2005; 69(1):75–80.

15. Kim KH, Sung MW, Roh JL, Han MH. Sclerotherapy for congenital lesions in the head and neck. Otolaryngol Head Neck Surg 2004; 131(3):307–16.

16. Mason KP, Michna E, Zurakowski D, Koka BV, Burrows PE. Serum ethanol levels in children and adults after ethanol embolization or sclerotherapy for vascular anomalies. Radiology 2000; 217:127–32.

17. Donnelly LF, Bissett III GS, Adams DM. Combined sonographic and ?uoroscopic guidance:a modi?ed technique for percu-taneous sclerosis of low-?ow vascular malformations. Am J Roentgenol 1999; 173:655–7.

18. Lee BB, Do YS, Byun HS, Choo IW, Kim DI, Huh SH. Advanced management of venous malformation with ethanol scler-otherapy:mid-term results. J Vasc Surg 2003; 37:533–8. C.-H. Lee, S.-G. Chen

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