For Complex Vascular Problems Teamwork is Key
Hemangiomas, port wine stains, and more serious venous, arterial, and lymphatic malformations all belong to a group of defects called vascular anomalies. This umbrella term encompasses tangled arteries, extraneous veins, dysfunctional lymphatics, and other defects in any of the tens of thousands of miles of vessels that carry blood and lymphatic fluid throughout the body.
Many vascular anomalies arise in the head and neck region, but they can develop in any part of the body reached by blood or lymphatic vessels, “and that’s everywhere,” notes June Wu, MD, a pediatric plastic surgeon with special expertise in vascular anomalies. Some anomalies are uncomplicated and don’t require medical intervention, while others are more serious and very challenging to treat, she says.
One of the most common forms of vascular anomaly—and the most common type of benign tumor in children—is infantile hemangioma, a proliferation of abnormal endothelial cells, the type of cells that make up blood vessels. Many hemangiomas do not require treatment and can be monitored closely for improvement over time, according to Maria Garzon, MD, director of pediatric dermatology. When hemangiomas do need treatment, Columbia's team takes into account many individual factors to tailor an approach for each patient. Medication (oral propranolol) is often the first step; if the hemangioma does not improve the team may turn to laser treatment or surgery.
The other major type of vascular anomaly is called vascular malformation. These are made of capillaries, veins, arteries, and lymphatic vessels, and can cause enlarged limbs, or growths on the neck or face or elsewhere on the body that interfere with vision, eating, and breathing or press inward on internal organs. Specialists at Columbia University Irving Medical Center treat these malformations using a number of different approaches.
Drs. Wu and Garzon are co-directors of Columbia’s multidisciplinary Vascular Anomalies Group, which has provided specialized care to infants, children, and adolescents with complex vascular problems for more than 15 years. The group includes specialists from dermatology; plastic, orthopedic, and pediatric surgery; cardiology, clinical genetics; diagnostic and interventional radiology; hematology; neurology; ophthalmology; and otolaryngology, who meet with patients and their parents during the twice-monthly vascular anomalies clinics.When serious anomalies are diagnosed during a routine prenatal ultrasound, the team expands to include specialists from Columbia’s maternal-fetal medicine division, who work closely with the rest of the team to determine the best course of action. “Our maternal-fetal medicine team is quite familiar with prenatal anomalies—we’re one of the tri-state referral centers for these cases,” Carrie Shawber, PhD, a vascular biologist in OBGYN, says. “The collaborative enterprise between Pediatrics and OBGYN starts before the baby is even born,” adds Dr. Garzon.
Nowhere is the collaboration more crucial than in rare cases where a complex mass of vessels grows large enough to impinge on a fetus’s airway, a high-risk, life-threatening situation. “This is a very tricky birth, because the baby may not be able to breathe once born,” says Dr. Wu. “In these emergency situations we sometimes have to perform a very complicated delivery called an EXIT procedure.” Before an EXIT (ex utero intrapartum treatment) procedure, the team carefully maps out the birth. The infant is partially delivered by caesarean section, a surgeon establishes an airway so the fetus can breathe, then the infant is fully delivered. A team of OBGYN, pediatric surgery, ENT, and neonatal specialists is present to support the infant and mother.
Another unique effort at Columbia is the team that includes Drs. Shawber and Wu, who are collaborating on research to identify and characterize the causes of vascular anomalies. “Our big research question is: what can we do to stop the natural history of these conditions in-utero?” says Dr. Shawber.
From before birth to the teen years and beyond, “we think about the lifelong impact of these disorders for the children and the family, and we have the expertise here to handle the entire range of them,” says Dr. Garzon. And, adds Dr. Shawber, “We can make a positive impact on the quality of their lives through proper care.”