Servier – Phlebolymphology

Vascular malformation classification: Hamburg or ISSVA classification?
A. Bisdorff Bresson

According to the author, the term “angioma” is often incorrectly used in literature to name both vascular tumors and vascular malformations. Vascular malformations are congenital developmental errors concerning the lymphatic, arterial, and/or venous system. They might be present at birth, but are not always seen. They can appear in childhood, adolescence, or adulthood, but will never disappear.

The Hamburg classification (1993) classifies the vascular malformations according to the type of predominant vessel. This classification system is used mainly by vascular surgeons. The classification differentiates between truncular and extratruncular lesions as well as between localized (limited) and infiltrating lesions.

The ISSVA classification (International Society for the Study of Vascular Anomalies) is the clinical classification that differentiates vascular tumors (hemangioma and others) from vascular malformations (Slow-flow: capillary malformation, venous malformation, lymphatic malformation; and Fast-flow: arteriovenous fistula, arteriovenous malformation).

In conclusion, both classifications are complementary, the ISSVA classification is a very simple binary classification with accurate clinical diagnosis, whereas the Hamburg classification is more complicated, but helpful for a better understanding and accurate treatment decision.

Embolic agents to treat venous and lymphatic malformations: an overview of the past 10 years.
A. Bisdorff Bresson

Venous malformations and lymphatic malformations are slow-flow malformations based on the ISSVA classification (International Society for the Study of Vascular Anomalies). Sclerotherapy is used to treat slow malformations and is most frequently performed by a direct puncture technique. We have liquid agents (foam, ethanol (ETOH), Bleomycine, A5, and Doxycycline), semiliquid agents (glue, Onyx, and Ethanol gel), permanent agents (plug and coils), and both endovenous thermal ablation and radiofrequency ablation. The choice of agent depends on lesion type, location, and extension.

In conclusion, sclerotherapy is an efficient treatment tool in venous malformations (VM) and lymphatic malformations (LM). Bleomycine seems to be promising agent in VM and LM, even though recurrence has been observed. The ethanol gel efficiency must be confirmed (high price and quantity issue). The endovenous laser treatment technique is an effective modality in small (<2 cm) skin and mucosal VM and can be associated with sclerotherapy. VMs and LMs require a Vascular Anomalies Center multidisciplinary approach (dermatologists, interventional radiologists, anesthesists, vascular surgeons, nurses, etc).