Vascular malformations

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the nomenclature and classification system of vascular malformations. 2. Evaluate these patients diagnostically. 3. Outline the surgical and nonsurgical options for treating these lesions. SUMMARY: Vascular anomalies can be classified into two unique groups-hemangiomas and vascular malformations-based on their endothelial properties. The present review focuses on vascular malformations rather than hemangiomas. The authors address capillary malformations, lymphatic malformations, venous malformations, and arteriovenous malformations. Diagnostic and therapeutic modalities are discussed with relevant case examples. A MEDLINE search was performed to gather all pertinent references. The physician treating these challenging lesions should ideally use a multidisciplinary team-based approach with multispecialty experience in diagnostic and therapeutic modalities for the management of vascular malformations.     

Congenital malformations associated with anencephaly in liveborn and stillborn infants

Records from the population-based British Columbia Health Surveillance Registry were examined, and a total of 456 infants with anencephaly (181 liveborns, 275 stillborns) were identified. Registry records list up to four congenital malformations per individual, and the records of the study cohort were reviewed for the presence of additional malformations. A total of 12.7% of infants (14.4% liveborns, 11.6% stillborns) had congenital malformations in addition to anencephaly. The frequencies of specific congenital malformations (e.g., talipes, cleft lip and/or palate, omphalocele) in infants with anencephaly were compared with the frequencies of these malformations in the general population of liveborns. In addition, the types of additional congenital malformations in liveborn anencephalics compared to stillborns were looked at. The similarity suggests that it is not just the presence of these additional congenital malformations that leads to death in utero. The data provide further evidence for etiological heterogeneity in neural tube defects.     

Notch receptor expression in human brain arteriovenous malformations

The roles of the Notch pathway proteins in normal adult vascular physiology and the pathogenesis of brain arteriovenous malformations are not well‐understood. Notch 1 and 4 have been detected in human and mutant mice vascular malformations respectively. Although mutations in the human Notch 3 gene caused a genetic form of vascular stroke and dementia, its role in arteriovenous malformations development has been unknown. In this study, we performed immunohistochemistry screening on tissue microarrays containing eight surgically resected human brain arteriovenous malformations and 10 control surgical epilepsy samples. The tissue microarrays were evaluated for Notch 1–4 expression. We have found that compared to normal brain vascular tissue Notch‐3 was dramatically increased in brain arteriovenous malformations. Similarly, Notch 4 labelling was also increased in vascular malformations and was confirmed by western blot analysis. Notch 2 was not detectable in any of the human vessels analysed. Using both immunohistochemistry on microarrays and western blot analysis, we have found that Notch‐1 expression was detectable in control vessels, and discovered a significant decrease of Notch 1 expression in vascular malformations. We have demonstrated that Notch 3 and 4, and not Notch 1, were highly increased in human arteriovenous malformations. Our findings suggested that Notch 4, and more importantly, Notch 3, may play a role in the development and pathobiology of human arteriovenous malformations.     

Trends in perinatal mortality attributed to congenital malformations in England and Wales during 1974-81: a study of the variations among regional health authority areas

Analysis of perinatal mortality attributed to congenital malformations in England and Wales, using data from birth and death registration over the years 1974-81 showed significant declines in England and Wales as a whole and in the individual Regional Health Authority (RHA) areas. A greater decrease in death rate from congenital malformations, particularly central nervous system malformations, was seen among stillbirths than among early neonatal deaths. There were marked regional differences in perinatal mortality due to central nervous system malformations over the period but not in cardiovascular system malformations or in other malformations. The highest mortality rates due to central nervous system malformations occurred in the North, North-West, West and South-West of England and in Wales, and the lowest rates in the South and South-East. The larger percentage reductions in the mortality rates were found in most of the regions which had had the highest rates. Possible explanations for the decline in regional rates are suggested.     

Comparative ultrasound and magnetic resonance diagnosis of fetal CNS malformations

The study was undertaken to optimize the diagnosis of fetal CNS and facial malformations, by using a complex of ultrasound (US) and magnetic resonance imaging (MRI) studies. A hundred and forty-four fetuses with suspected CNS and facial malformations were examined. The US study conducted by a specially developed protocol was supplemented by MRI (48 fetuses) also made by a specially developed protocol. Various fetal CNS malformations, such as neural tube defects, congenital endbrain malformations, cystic lesions, tumors, ventricular complex anomalies, defects of the face and eyes, multiple defects, including CNS and facial anomalies, were detected. With MRI, the diagnosis was changed in 33% of cases. The application of a complex of US and MRI studies enhances the efficiency of diagnosis of congenital CNS and facial malformations in the fetus. MRI in the diagnosis of fetal CNS and facial malformations has a number of advantages and should be used if there is some difficulty in establishing a diagnosis when an US study is performed.     

A locus for hereditary capillary malformations mapped on chromosome 5q

Capillary malformations (port-wine stains) are the most common vascular malformations occurring in 0.3% of live births. Most capillary malformations occur sporadically and present as a solitary lesion. Capillary malformations can also occur as a component of well-described syndromes. Familial occurrence of multiple capillary malformations has been described in the literature, suggesting autosomal dominant inheritance with variable expression in this subgroup. A hereditary basis underlying the development of solitary capillary malformations has not been found, but may well be possible. We have mapped a locus for an autosomal dominant disorder in a three-generation family that manifested itself with multiple cutaneous capillary malformations to chromosome 5q13-22. This locus spans 48 cM between the markers D5S647 and D5S659 and harbours several candidate genes. By defining the gene(s) responsible for capillary malformations, we will gain more insight in the pathogenesis of this disorder. It is likely that genes implicated in these familial cases may be involved in the more sporadic cases.     

VACTERL/VATER Association

Congenitally corrected transposition is a rare cardiac malformation characterized by the combination of discordant atrioventricular and ventriculo-arterial connections, usually accompanied by other cardiovascular malformations. Incidence has been reported to be around 1/33,000 live births, accounting for approximately 0.05% of congenital heart malformations. Associated malformations may include interventricular communications, obstructions of the outlet from the morphologically left ventricle, and anomalies of the tricuspid valve. The clinical picture and age of onset depend on the associated malformations, with bradycardia, a single loud second heart sound and a heart murmur being the most common manifestations. In the rare cases where there are no associated malformations, congenitally corrected transposition can lead to progressive atrioventricular valvar regurgitation and failure of the systemic ventricle. The diagnosis can also be made late in life when the patient presents with complete heart block or cardiac failure. The etiology of congenitally corrected transposition is currently unknown, and with an increase in incidence among families with previous cases of congenitally corrected transposition reported. Diagnosis can be made by fetal echocardiography, but is more commonly made postnatally with a combination of clinical signs and echocardiography. The anatomical delineation can be further assessed by magnetic resonance imaging and catheterization. The differential diagnosis is centred on the assessing if the patient is presenting with isolated malformations, or as part of a spectrum. Surgical management consists of repair of the associated malformations, or redirection of the systemic and pulmonary venous return associated with an arterial switch procedure, the so-called double switch approach. Prognosis is defined by the associated malformations, and on the timing and approach to palliative surgical care.     

Use of magnetic resonance imaging for the evaluation of vascular malformations of the lower extremity

Vascular malformations are anatomically subdivided according to the predominant channel anomaly into either capillary, arterial, venous, lymphatic, or combinations. They can be further subdivided into high- or low-flow malformations. Any lesion that has an arterial component is considered a high-flow malformation. Once the diagnosis of a vascular malformation is made, it is of paramount importance to define not only the flow characteristics but also the full range of extension, because the prognosis and appropriate treatment vary substantially for each type of anomaly. The two most useful noninvasive imaging techniques for assessing vascular malformations are magnetic resonance imaging (MRI) and ultrasonography. The aim of this review is to give surgeons involved in treating patients with vascular malformations an opportunity to gain some background on MRI scans when assessing vascular malformations. Although MRI is a powerful modality for assessing vascular malformations, we will also discuss some of the limitations of MRI. We further suggest a diagnostic flow chart developed on the basis of MRI features designed to help determine the composition of a vascular birthmark when intervention is anticipated.     

Study of placenta of children born with congenital malformations

The malformations in this study were observed in a series of 279,642 consecutive births of known outcome registered in our Registry of congenital anomalies. For each case, more than 50 factors included in the registration forms were studied. One of the factors studied was the placenta. For each malformed child, a control was chosen. Cases with maternal known factors impairing placenta function, i.e. vasculopathy and diabetes, were excluded. In each category of malformations studied, the malformed children were divided into isolated and non-isolated (multiple malformed) cases. The weight of placenta of isolated cases was not lower than the weight of placenta of the controls. In contrast, the weight of placenta of the cases with non-isolated malformations was lower than the weight of placenta of the controls and of the isolated cases, for all categories of malformations but gastroschisis and omphalocele. The mean weights at birth of the cases with multiple malformations were also lower than those of the controls. The human placenta discounts a principal functional part, the maternal blood in the intervillous space. Congenital malformations may interact with this function.     

Lethal malformations and perinatal mortality: a 10 year review with comparison of ethnic differences.

During 1976 to 1985 perinatal mortality in Leicestershire decreased from 21 to 9.5 per 1000 births. Throughout this period the incidence of lethal malformations, excluding neural tube defects, remained relatively constant at around 1.8 per 1000 births. Analysis of the malformations present in 201 lethally malformed babies showed that 147 (73%) had a disorder carrying a recurrence risk of 1% or greater. Only 7% of these malformations might have been predicted from the family history or advanced maternal age. The incidence of lethal malformations was significantly increased in the Asian population, largely because of an excess of autosomal recessive disorders. The contribution of lethal malformations to perinatal mortality has almost doubled over the past 10 years and is likely to increase despite prenatal diagnosis and improvements in obstetric and paediatric services.     

CHARGE Association in newborns: a registry-based study

The CHARGE Association is a nonrandom occurrence of congenital malformations that has been described in clinical series. Reported patients have been selected on the basis of certain prior criteria. In this article, we try to identify a congenital malformation pattern corresponding to the CHARGE Association, using statistical methods and analyzing 5,260 infants with multiple malformations collected from four large registries of congenital malformations. Care was taken to identify a number of confounding characteristics that can influence the ascertainment and registration of specific congenital malformations. We have identified a cluster of malformations that generally agreed with the current clinical definition of the CHARGE Association and have added some further malformations (e.g., facial clefts). We demonstrate that others (e.g. , esophageal atresia) are probably not part of the pattern. Heart defects (H in the acronym) seems to be less helpful in identifying infants with the association. We suggest a method to select infants who probably represent the CHARGE Association for analyses of possible risk factors.     

Types of anatomic correspondence between the conducting system and the heart

The principles of a quantitative determination of characteristics concerning the types of anatomical correspondence between the conduction system and the heart at its congenital malformations are presented. This makes it possible to establish that the topographoanatomical type of the conduction system depends on the peculiarities of the heart structure at its congenital malformations rather than from changes in the structure and position of the parts of the conduction system, or the conduction system as a whole according to the types of congenital heart malformations. The mechanism of the left-sided position of the atrioventricular bundle (His bundle) in some congenital malformations of the heart is explained.     

"Teratologic series" and their genetics]

Isolated cyclopia is one of the members of the prosencephalic teratologic series. In some families with cyclopian monster other types of prosencephalic malformations are found in sibs or more distant relatives. All these malformations occur more frequently in females. Different forms of prosencephalies are observed in the same type of chromosome disbalance. These data suggest that morphogenesis and etiology of the prosencephalic malformations are common. Therefore a whole teratologic series but not a single member-malformation must be an object of genetic analysis. The same data are found for another teratologic series: bilateral renal agenesis--unilateral one--aplastic variant of the cystic dysplasia of kidneys. Polygenic inheritance with the threshold phenomenon is the most probable type of genetic determination of such malformations. The more frequent occurrence of polygenic malformations in families with the studied malformation whose inheritance is not yet established may be an indirect indication for the polygenic determination of the latter.     

Amphibian malformations and inbreeding

Inbreeding may lead to morphological malformations in a wide variety of taxa. We used genetic markers to evaluate whether malformed urodeles were more inbred and/or had less genetic diversity than normal salamanders. We captured 687 adult and 1259 larval tiger salamanders (Ambystoma tigrinum tigrinum), assessed each individual for gross malformations, and surveyed genetic variation among malformed and normal individuals using both cytoplasmic and nuclear markers. The most common malformations in both adults and larvae were brachydactyly, ectrodactyly and polyphalangy. The overall frequency of adults with malformations was 0.078 compared to 0.081 in larval samples. Genetic diversity was high in both normal and malformed salamanders, and there were no significant difference in measures of inbreeding (f and F), allele frequencies, mean individual heterozygosity or mean internal relatedness. Environmental contaminants or other extrinsic factors may lead to genome alternations that ultimately cause malformations, but our data indicate that inbreeding is not a causal mechanism.     

Congenital developmental defects in the genetic monitoring system. I. The selection of developmental defects subject to dynamic observation

The requirements for selection of congenital malformations in the system of genetic monitoring as models have been studied. Model malformations have been shown to be easily and reliably diagnosed even in infancy. Their rate should be not less than 1:5000 births. The precise knowledge of the genetics of model forms is needed as well. Down's syndrome registration is the most convenient method for evaluation of mutations in a genome. We recommend registration in total all multiple congenital malformations (without Down's syndrome) for estimation of dominant mutability dynamics, as it was shown that more than 11% of all multiple malformations are caused by sporadic dominant mutations.     

Genetics, chance, and morphogenesis.

We posit that chance plays a major role in the occurrence of many common malformations that cluster in families but recur less frequently than expected for simple Mendelian traits. Once the role of random effects is accepted, the segregation of such malformations may be explained on the basis of Mendelian transmission of a single abnormal gene that predisposes to, but does not always result in, the abnormal phenotype. We apply a stochastic (probabilistic) single-gene model to the occurrence of malformations in mouse and man. The stochastic single-gene model suggests the feasibility of isolating individual genes that determine morphogenesis and sets limits on the precision with which the recurrence of malformations can be predicted.     

Associated malformations in cases with neural tube defects

Infants with neural tube defects (NTDs) may have other associated congenital defects. The reported incidence and the types of associated malformations vary between different studies. The purpose of this investigation was to assess the prevalence of associated malformations in a geographically defined population. The prevalences at birth of associated malformations in infants with NTDs were collected between 1979 and 2003 on all infants born in the area covered by the registry of congenital anomalies of Northeastern France in 334,262 consecutive births. Of the 360 infants with NTDs born during this period, 20.5 % had associated malformations. Associated malformations were more frequent in infants who had encephalocele (37.5 %) than in infants with anencephaly (11.8 %) or infants with spina bifida (23.7 %). Malformations in the face (oral clefts), in the musculoskeletal system, in the renal system, and in the cardiovascular system were the most common other anomalies. In conclusion the overall prevalence of malformations, which was one in five infants, emphasizes the need for a thorough investigation of infants with NTDs. A routine screening for other malformations especially facial clefts, musculoskeletal, renal and cardiac anomalies may need to be considered in infants with NTDs, and genetic counseling seems warranted in most of these complicated cases.     

Malformations in rat fetuses induced by trypan blue

Malformations of fetuses obtained from Wistar rat dams treated with trypan blue during gestation were studied. Fetuses were examined on day 20 of gestation. One hundred and twenty-seven fetuses showed abnormalities of the external features, skeleton and internal organs, separately or in combination. External malformations were found in 108 fetuses. The most frequent external malformation was anomaly of tail. Spina bifida, club foot, exencephaly and anal atresia were also observed frequently. Skeletal malformations were detected in 48 fetuses. Deformity of vertebrae in the lumbar, sacral and/or caudal regions was found in 46 fetuses. Internal malformations were observed in 27 fetuses. Anomaly of heart and/or great vessels, hydrocephaly and micro- or anophthalmia were observed frequently. About 90% of the fetuses with skeletal malformations also showed some external malformations. In contrast, about 48% of the fetuses with internal malformations also had some external malformations. These results suggest that, for teratological study, internal examination is more important in detecting malformations of fetuses than skeletal examination.     

Teratogenicity of zinc deficiency in the rat: study of the fetal skeleton

Zinc deficiency (ZD) is teratogenic in rats, and fetal skeletal defects are prominent. This study identifies fetal skeletal malformations that affect calcified and non-calcified bone tissue as a result of gestational zinc deficiency in rats, and it assesses the effect of maternal ZD in fetal bone calcification. Pregnant Sprague-Dawley rats (180-250 g) were fed 1) a control diet (76.4 micrograms Zn/g diet) ad libitum (group C), 2) a zinc-deficient diet (0 microgram/g) ad libitum (group ZD), or 3) the control diet pair-fed to the ZD rats (group PF). On day 21 of gestation, laparotomies were performed. Fetuses were weighed, examined for external malformations, and stained in toto with a double-staining technique for the study of skeletal malformations. Maternal and fetal tissues were used for Zn, Mg, Ca, and P determinations. Gross external malformations were present in 97% of the ZD fetuses. No external malformations were found in fetuses from groups C and PF. Ninety-one percent of cleared ZD fetuses had multiple skeletal malformations, whereas only 3% of the fetuses of group PF had skeletal defects; no skeletal malformations were found in fetuses from group C. Some of the skeletal malformations described in the ZD fetuses, mainly affecting non-calcified bone, were not mentioned in previous reports, thus stressing the importance of using double-staining techniques. Examination of stained fetuses and counting of ossification centers revealed important calcification defects in ZD fetuses. These effects were confirmed by lower Ca and P concentrations in fetal bone with alteration of the Ca:P ratio.     

Importance of genetic predisposition and maternal environment for the occurrence of congenital malformations in offspring of diabetic rats

Previous experimental studies have implicated a genetic component in the induction of malformations in the offspring of diabetic rats. We have compared the outcome of diabetic pregnancy in two outbred (sub)strains of Sprague-Dawley rats (with low incidence [H] and high incidence [U] of skeletal malformations in the offspring) and hybrids between them. The fetuses of diabetic H mothers had no skeletal malformations and the lowest frequency of resorptions (8-9%), regardless of embryo type (H/H or H/U). When the diabetic mother was U or from the hybrid strain (H/U) and the offspring were of the mixed H/U type, we found increased resorption (16-21%) and skeletal malformation (3-5%) rates. If instead the embryos contained a major U genome [either U/U or U/(H/U)], further increased resorptions (23-30%) and skeletal malformations (17-19%) resulted. The H/H and U/U embryonic susceptibility to defined teratogens (3-6 mg/ml D-glucose, 4-8 mM B-hydroxy-butyrate) were compared in whole embryo culture and found to be similar, suggesting that the malformations occurring in vivo may have a different etiology than those found in vitro. In the rat model studied, diabetes in the mother appears to cause a disturbance of early stages of embryogenesis in genetically predisposed embryos. This early disturbance results in skeletal malformations and seems to require inducing factor(s) in addition to increased levels of D-glucose and B-hydroxybutyrate. The findings are in concert with the notion of a mixed genetic-environmental etiology of malformations in (diabetic) pregnancy.