Laserbehandeling van vasculaire anomalieën

Laserbehandeling van vasculaire anomalieën

1/12/2015
Laserbehandeling van
vasculaire anomalieën
M.Morren, dienst huidziekten (pediatrische dermatologie)
A Van Laethem, lasercentrum dermatologie
UZ Leuven
[email protected]
• Vascular anomalies : classification
• Laser principles
• Indications and results
1.
2.
3.
4.
Infantile hemangioma
Capillary vascular malformation
Venous malformation
Lymphatic malformation
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CM+VM
…
CM+LM+VM+
AVM
Anomalies in origin,
course, number,
lenght, diameter or
valves mostly of
large axial vessels
and AV fistulas
Bv. Klippel-Trenaunay
Parkes-Weber
Cloves
Proteus
Macrocephaly CM
Vascular malformations : look alikes!
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Vascular malformations : look alikes!
• Vascular anomalies : classification
• Laser principles
• Indications and results
1.
2.
3.
4.
Infantile hemangioma
Capillary vascular malformation
Venous malformation
Lymphatic malformation
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Laser system: basic concept
monochromatic
coherence
collimation
Medium = Laser name
gas (CO2, argon, excimer); liquid (PDL); solid (alexandrite, diode, Nd:YAG )
L
light
A
amplification
S
stimulated
E
emission
R
radiation
Interaction between Laser light and tissue
Absorption
chromophore
•
•
•
Water
Melanin pigment
Hemoglobine
• tattoo pigment
• photosensitizer
Photothermolysis
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Laser Light: parameters
1.
wavelenght
2.
Energy (Fluence)
3.
Pulse width ( < of = Thermal Relaxation Time)
oxyHb/deoxyHb
1
Wavelenght
Absorption spectrum of
natural chromophores
target selectivity
Melanin
External
chromophores
water
determines choice of laser
Selective photothermolysis “Anderson and Parish”
matching wavelenght with absorption peak target
chromophore :
->improve efficacy
->minimize nonspecific thermal damage
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Excimer Er CO2Argon KTP PDL Ruby
Penetration
depth
Alex
Diode Nd:YAG
≈ lenght of the wavelenght
2 mm
determines choice of laser
5-6mm
2
Energy
Energy Fluence
= amount of energy delivered in a single pulse
Joule/ cm2
Spot size
larger spot size  less scatter 
more energy delivered at the target +
deeper penetration
adapt fluence to the skin site
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3 Pulse width
< of = Thermal Relaxation Time (TRT)
= time needed to loose 50% of absorbed heat without conduction to the
surrounding tissue
depending on the size of the target
Indications <-> chromophore
1.Vascular lesions (Hb)
2.Pigment en tattoos (melanin, external)
3.Epilation (melanin)
4.Ablative photothermolysis (water)
- tumors
- scars
- skin tightening
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Vascular lesions
Vascular lasers
nm
Target chromophore: (oxy)hemoglobin
(Argon
488-514)
KTP
532
PDL
585-595
Alexandrite
755
Nd:Yag
1064
IPL
500-670
870-1400
• Vascular anomalies : classification
• Laser principles
• Indications and results
1. Infantile hemangioma
2. Capillary vascular malformation
Naevus Unna
Naevus flammeus (USA)!
3. Venous malformation
4. Lymphatic malformation
5. Acquired lesions : spider nevus
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1. Vascular tumors : infantile hemangioma
if treatment required : functional, (risc) of ulceration), (cosmetic)
PDL (repeat every 3w)
1st line: propranolol 2-3 mg/kg/d
LASER
-
??
very early, macular lesions
residual telangiectatic lesions
residual fibro-adipous tissue
PDL, KTP, Nd:YAG
fx CO2
Side effects/ (Lancet. 2002;360:521-7)
Hypopigmentation-Ulceration-Atrophy-scarring- induction of
proliferation
2 weeks propranolol
Age 3,5 y
after 2 years
propranolol
4x PDL
laser
2x PDL
laser
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Diffuse neonatal hemangiomatosis
after PDL
Infantile hemangioma: associated with other anomalies
• Phaces : segmental hemangioma face +
o
posterior fossa malformations,
o
arterial anomalies,
o
cardiac defects,
o
and eye anomalies
• Lumbar or Pelvis : segmental hemangioma genital area +
o
malformations of external genitalia,
o
lipomyelomeningocele,
o
vesicorenal abnormalities,
o
imperforate anus
o
skin tag
BMC Pediatr. 2015 Oct 8;15:150
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2. Capillary vascular malformation
•
•
•
•
0,3- 0,6% of newborns
M/F : 1/1 to 1,5
Hereditary in 8-27%!
Special entities :
o
Sturge Weber syndrome
o
Klippel-Trenaunay
o
Parkes-Weber
o
Cobb syndrome
o
CM-AVM syndrome
Sturge Weber
Klippel Trénaunay
CM-AVM syndrome
Arch Dermatol. 2012;148(11):1334
Etiopathogenesis of capillary vascular malformations
• Solitary CVM:
in 75-92% somatic GNAQ c.548G>A mutations
o Other somatic mutations : GNAQ c.547 C>G, SMARCA, EPHA3,
MYB, PDGFR-BETA,PIK3CA
Sturge-Weber syndrome : 80-88% somatic (brain, skin) GNAQ
c.548G>A
Activation of ERK, Junc pathways
CM-AVM syndrome : Germ-line RASA-1 mutations
Familial CVM : no germline RASA-1 mutations
o
•
•
New Engl J Med 2013; 368; 1971
Plos One 2015; 10 : e0133158
Am J Hum Genet 2003;73; 1240
J Cosm and Laser therapy 2015; 17: 204
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Capillary vascular malformation
Early lesions
Port wine stain
Capillary vascular malformation
Old lesions
Port wine stain
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Cochrane review vascular lasers for CVM
Cochrane Database Syst Rev. 2011 Nov 9
• 5 RCT using within patient design
• PDL is most efficient = still treatment of choice for CVM
50 to 100% of patients have > 25% reduction of
redness after 1-3 treatments
• PDL 595 with cooling is preferred by patients
• Nd-Yag 1064 is preferred because of shorter lasting
purpura (but less effective)
• IPL is much less effective
o
PDL is standard treatment
Laser treatment scheme
gradual improvement
5-10 treatments
TEST
1st consultation
6-8m
1st treatment
4-8w later 2nd tr …
7 tr
4w documentation result
and reimbursement
request
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Reimbursement rules
• Only for lesions located in the face,
supraclavicular neck region and hands
• Long procedure : lasts months
o Tests (2nd if no result with first)
o Reading of test result (after 1 month)
o Paperwork (social insurance (local->central)->
bijzonder solidariteitsfonds -> all way back!)
• Maximal 8 sessions reïmbursed
When to treat?
• As early as possible?
Smaller vessels
o More superficial vessels
o No hyperplasia
o Psychological advantage
• Not during summer (or sun exposition)
• Sequence of treatments : advantage if less than one
month in between treatments?
o
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Before R/
After 3 R/
After 10 R/
After 11 R/
test result
after 1 tr
after 3 tr (2 thoracal)
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• Painfull procedure
o
o
Topical anesthesia (Rapidan° better than EMLA)
General anesthesia for children:
• Better patient comfort
• Less risk of overlapping pulses
• Risk of anesthesia in young children?
Results of laser treatment
• 10 %: Very good result > 90% fading
After 4 R/
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Results of laser treatment
• Majority : fair result : between 25% and 75% fading
After 6 R/
After 4 R/
After 3 R/
Results of laser treatment
• 10-20% : Poor result : minimal fading or no clearing at all
After 10
R/
after 3 R/ with
higher
Fluence and
stacking
After 7 R/
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Side effects of treatment with vascular lasers
• Immediate : (purpura), blisters, crusting, pain
• Late complications :
o
o
Tran
sient
< 2m
o
o
Scarring atrophic : 1,4%
hypertrophic : 0,7%
Hyperpigmentation :1-40% : skin type
IV and V
Hypopigmentation : < 1%
Alopecia (eyebrows)
After 6m
Prognostic factor : bad final result laser
+ redarkening (neovascularisation)
after 5y in 16-50%
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If failure of PDL treatment : future options
(most experimental)
• KTP laser but no real advantage over PDL
more hyperpigmentation
• Deeper vessels : Alexandrite or Nd-Yag 1064 nm
o But : more side effects, scarring and
hyper/hypopigmentation
• Small vessels : pneumatic skin flattening
• Overall more effective : photodynamic (+ visible light)
Photodiagnosis Photodyn Ther. 2009 Sep-Dec;6(3-4)
• Indocyanine green augmented (+ diode)
If failure of PDL treatment : future options
(most experimental)
• Combination therapies
o
o
o
PDL and Nd Yag (metHb formation)
PDL and fractionated ablative laser
IPL (band of wavelenghts between 500-670 nm and 870-1400 nm )
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If failure of PDL treatment : future options
(most experimental)
• Inhibiting new angiogenesis
Combination with topical rapamycin
o
“
“
with imiquimod
o
“
“
with axitinib
• Enhancing thrombosis of partly photocoagulated vessels
locally delivered thrombotic or anti-fibrolytic agents
o
Lasers in Surgery and Medicine 44:796–804 (2012)
J Am Acad Dermatol. 2015 Jan;72(1):151-8.e1
Lasers Surg Med. 2015
Br J Dermatol. 2015 March ; 172(3): 669–676
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New vascular classification of port-wine stains: improving
prediction of Sturge–Weber risk
British Journal of Dermatology (2014) 171
Algorythm
British Journal of Dermatology (2014) 171
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3. Venous malformations
•
Venous
•
Arterial
2x Nd:YAG LP
Screening with Duplex echo (mass and flow)
4. Lymphatic malformations
•
Capillary
•
Venous
•
Arterial
•
Lymphatic
CO2 ablative
followed by
fractionated
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