and functioned in collaboration with a wide range of specialists—IR, DR, plastic surgery, ENT, orthopedic surgery, general surgery, occupational therapy, physical therapy, psychology and genetics. The clinic is 1 full day a week, and patients will come from all over—even internationally—to be seen at our center.
Though not all specialists are present in the clinic at one time, this program has allowed streamlined care for our patients.
The need for collaboration As stated, the scope and variability of vascular anomalies requires that multiple specialties play a role in treatment. For example, if a lymphatic malformation involves the airway, ENT is usually required as a consultant. Some superficial lesions involve the skin, which necessitates the involvement of dermatologists. Oncology has become core to the management of vascular anomalies because we have found that the molecular drivers of these lesions are very similar to those in tumors, due to similar mutations and signal transduction pathway changes. This led to the discovery of the application of oncologic medications to the treatment of vascular anomalies, particularly with very diffuse and morbid lesions. In these cases, standard interventions or surgery will not be feasible for bringing these lesions under control. However, once we find a mutation in the lesion, systemic targeted therapy has shown excellent results in quite a few cases.
The wide range of vascular anomalies means that while one lesion can be very focal, another can be very diffuse and affect numerous areas in the body, causing multiple types of morbidity. Effective management for extensive lesions requires not only interventional specialties, but also physical or occupational therapy. In addition, some of the more severe anomalies can have pervasive psychosocial impacts on patients and families, which is why social work and sometimes child psychologists will be involved as well.
The role of IR in vascular anomalies At my institution, IR is deeply involved in the vascular anomaly clinic because
While the treatment of vascular anomalies utilizes guidance from many other specialties, it’s not unusual—especially at a pediatric hospital—for collaborative care to be the standard across many service lines.
we are one of the core specialties that manages vascular anomalies. This is because many IR techniques and technologies are well suited for treating vascular lesions. While a lesion on the musculoskeletal system would be the purview of an orthopedic surgeon, and a lesion on the airway would be the domain of an ENT surgeon, IR can be involved in the management of these lesions regardless of location. Although surgery can play a role in the management of these patients, the minimally invasive nature of IR therapies often makes our techniques more attractive.
When we first see a patient in clinic, we assess them by going through the imaging and performing a brief physical examination, make our best judgment on the diagnosis and management and present it to the multidisciplinary team. We also run a clinical conference each week to discuss patient care and recommendations. Sometimes, based on the lesion and presentation, we may elect not to do any procedure. Sometimes, if the diagnosis is unclear, we will biopsy a lesion.
If the diagnosis and benefits of procedure are clear, we will treat the lesion through several different therapies. Sclerotherapy is used largely for slow-flow vascular anomalies. These are anomalies that predominantly have veins or lymphatic channels in them. For high-flow lesions, we will embolize. Certain vascular anomalies are amenable to cryoablation, which
is sometimes more effective than sclerotherapy or embolization.
After performing a standard evaluation for the management of the patient in clinic, we will schedule a date for them to return and undergo the procedure, often with anesthesia. Patients return to our personal clinics for the procedure and follow-up and we make our next recommendations based on the outcome of the initial intervention.
The collaborative spirit of pediatric care While the treatment of vascular anomalies utilizes guidance from many other specialties, it’s not unusual—especially at a pediatric hospital—for collaborative care to be the standard across many service lines. For example, IR is part of the hepatobiliary service line alongside the liver transplant team, gastroenterology and surgery. Thyroid patients will often be seen by IR, endocrinology and thyroid surgeons. Even our motility service, consisting of gastroenterology subspecialists and surgeons, will send patients to IR for cecostomy and other forms of enteral access. Almost every service line within the pediatric system ends up being multidisciplinary to various degrees.
Perhaps this collaborative spirit is easier to achieve because it is part and parcel of caring for children—following the credo that “it takes a village.” Pediatric specialties are supportive of each other, in my experience. Parents are often very involved in their child’s care plans and become well educated on the various specialties that may be involved, and so they often expect a high level of collaboration. This expectation enables physicians to work together more easily. As a result, we become united in care, right alongside the family of our patients, and the collaborative spirit follows.
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