Retrospective study of hematologic complications in patients with slow‐flow vascular malformations undergoing sclerotherapy

Abstract

Background Slow‐flow vascular malformations (SFVM) are associated with localized intravascular coagulopathy (LIC), which is characterized by elevated D‐dimer and, when severe, hypofibrinogenemia. LIC results in intralesional clotting and hemorrhage and increases risk for significant thrombotic and bleeding complications. Sclerotherapy has been a suggested potential trigger for LIC worsening to disseminated intravascular coagulopathy. Hematologic complications of sclerotherapy in SFVM, along with low‐molecular‐weight heparin (LMWH) used to prevent worsening LIC, are largely unstudied. Procedure Medical records of patients with SFVM and LIC who underwent sclerotherapy at Cincinnati Children's Hospital Medical Center from July 2008 to December 2016 were reviewed for periprocedural hematologic complications. LMWH dose, frequency, and course length were evaluated. Results Fifty‐nine patients with SFVM and LIC underwent 281 sclerotherapy procedures, of which 86% were in children. Eighty‐five percent of patients received periprocedural LMWH, although at various doses and course lengths. No thrombotic complications occurred in children. One adult on LMWH developed pulmonary emboli after sclerotherapy. No major bleeding complications occurred postoperatively. In four patients, fibrinogen dropped below 100 mg/dL post‐sclerotherapy, requiring cryoprecipitate. One patient required packed red blood cell (RBC) transfusion for sclerotherapy‐induced hemolysis. No intraoperative bleeding or thrombotic events occurred. Conclusion LMWH use, at subtherapeutic dosing, was common in this patient population and did not appear to increase risk of significant bleeding before, during, or after sclerotherapy. In children with SFVM, bleeding and thrombotic complications after sclerotherapy appear rare. Although safe, prospective studies are needed to evaluate the efficacy of LMWH to prevent worsening coagulopathy with procedures.

Coagulopathy and related complications following sclerotherapy of congenital venous malformations

“…A previous study reviewed a similar population with VM in which 85% of patients with LIC received anticoagulation pre‐, intra‐, or postoperative at various dosing and times, with 55% ( N = 34) receiving LMWH 0.5 mg/kg/day once a day for 2 weeks before and after sclerotherapy. In this cohort, there was no increased risk of bleeding related to anticoagulation peri‐procedure, but there were rare thrombotic and/or bleeding complications post sclerotherapy, including one patient with postoperative VTE and four patients with minor bleeding 15 …”

“…These findings suggest that peri-procedural anticoagulation may not be necessary in patients with pre-sclerotherapy laboratory data suggesting a diagnosis of LIC. Although Ricci et al showed that peri-procedural, subtherapeutic LMWH dosing did not appear to increase the risk of significant peri-procedural bleeding, 15 anticoagulation is often expensive, as well as anxiety provoking, for patients/patient families, and possesses an inherent risk of bleeding. 18 Anticoagulation is still necessary in some patients with congenital VM, regardless if procedures are planned.…”

“…Although Ricci et al. showed that peri‐procedural, subtherapeutic LMWH dosing did not appear to increase the risk of significant peri‐procedural bleeding, 15 anticoagulation is often expensive, as well as anxiety provoking, for patients/patient families, and possesses an inherent risk of bleeding 18 …”

“…In this cohort, there was no increased risk of bleeding related to anticoagulation peri-procedure, but there were rare thrombotic and/or bleeding complications post sclerotherapy, including one patient with postoperative VTE and four patients with minor bleeding. 15 The purpose of this study is to evaluate the rate of LIC in children with congenital VMs undergoing sclerotherapy as the primary treatment for their malformation. A secondary aim is to describe the clinical characteristics of VM and LIC in patients treated with sclerotherapy and any coagulopathy-related procedural complications such as DVT/pulmonary embolism (PE) and bleeding.…”

How we approach coagulopathy with vascular anomalies.

“…Figure 3 summarizes our current approach to these patients. While LMWH has been the anticoagulant most used 49 , some have experience with direct oral anticoagulants (DOAC) as an alternative 42,44,[50][51][52] . DOAC may be a reasonable therapy post-operatively for patients at low risk of bleeding or who are strongly opposed to a subcutaneous injection.…”