Case#11

History: Middle-age woman with a painful elbow lesion; history of failed surgical procedure. A surgical scar is obvious over the lesion (not presented here). The patient describes pain and discomfort in the elbow, which limits her daily activities. 

• Arteriogram (Arteriography) (not presented here): The lesion demonstrated delayed opacification with no arterial involvement.  
• MRI (see below): T2 weighted axial images through the elbow demonstrate hyperintense (bright) lesion in the muscles extending into the subcutaneous area. The margins of the lesion are sharp, but irregular. The lesion is located around the brachial artery and major nerves which makes surgical excision very difficult, if not impossible (without major sequela). 

• Venogram (see below, first image) was obtained with contrast injection via a superficial vein in the hand. Venogram is generally needed to make sure that there are patent deep veins and also to obtain a baseline venous anatomy. Venous access is usually maintained and is used for flushing the deep veins during the procedure so that potential sclerosant drainage into the deep venous system would not cause thrombosis (deep vein thrombosis).
• Direct puncture of the malformation (2nd image) under ultrasound guidance and intralesional contrast injections outlines the malformation and also demonstrate the drainage pathways. This is an important step in sclerotherapy in order to limit potential complications of the procedure. With adequate venous outflow control, sclerosant agent mixed with contrast material (ethiodol) is then injected into the malformation under careful fluoroscopic control. During these sclerosant injections, it is important to make sure that sclerosant solution is being infused into the malformation, not into the surrounding soft tissues and the sclerosant solution is not being drained rapidly into the systemic circulation. 

Diagnosis: Venous Malformation. 

Treatment: This lesion can not be excised completely (surgically) (please see the discussion above) . In this patient, most appropriate therapeutic approach would be direct percutaneous sclerosant injection (sclerotherapy). Long term result of this procedure is not known yet.