(23) Combined glue embolization and surgical excision for management of pediatric and adolescent patients assigned female at birth with genitourinary and perineal vascular anomalies

Background: Vascular anomalies (VA) encompass a broad range of tumors and malformations of the capillaries, arteries, veins or lymphatics. Often diagnosed in birth to childhood, VA affect around 5% of children, of whom an estimated 2-2.6% have genitourinary and perineal (GUP) involvement, which may contribute to pain, debility, and aesthetic concerns. A recent innovation in surgical management for VA is n-BCA glue embolization followed by surgical excision. This study reviews the technical success and clinical outcomes of this combined surgical approach for management of GUP-VA.

Case: For this IRB-approved retrospective chart review, patients assigned female at birth with GUP-VA who underwent glue embolization and surgical excision were identified from a large database of patients with VA who presented for care to a tertiary-care children’s hospital from 1998-2024. Demographics, operative procedure and complications, and prior and subsequent treatment history were reviewed.

Five female patients with GUP-VA underwent glue embolization and excision (mean age 13 years, range 3-22) between 2014-2023. Four patients presented with congenital vulvar arteriovenous or venous malformations, while one patient developed a perineal body venous malformation secondary to saddle injury. Indications for treatment included swelling (100%), pain (40%) and bleeding (20%). Two patients had undergone prior therapies, including sclerotherapy (n=1) and prior surgical excision with eventual symptom recurrence (n=1). Embolization was performed with 1:3 or 1:4 n-BCA glue in ethiodized oil. Mean lesion size was 2.9 x 2.1 x 1.4 cm. Three patients underwent excision immediately post-embolization, while two patients underwent excision the following day. The procedure was technically successful in 100% of patients: symptomatic improvement was achieved in all patients, and none experienced VA recurrence. There was one instance of nontarget glue thromboembolism to a segmental pulmonary artery; suction thrombectomy removed the majority of the glue thrombus without any change in patient's oxygenation status and no large filling defects on pulmonary arteriography. Excision procedures were uncomplicated; mean and median surgical blood loss volumes were 46 and 50 mL. One patient experienced wound separation and was monitored for wound healing by secondary intention. Mean and median follow-up duration were six and three months (range 1-14 months).

Comments: Combined glue embolization and excision is a safe and effective treatment option for pediatric and adolescent patients presenting with GUP-VA.