Super glue. What can’t it do?
Fix a broken flower vase? Check.
Hold together a Halloween costume? Check.
Allow surgeons to safely remove tangled clumps of extra veins that are otherwise tricky and dangerous to treat? Check.
That’s right. A team from Seattle Children’s has pioneered a safer method to remove venous malformations in the head and neck by first injecting them with n-butyl cyanoacrylate (n-BCA) glue, a medical variation of the familiar household super-adhesive.
The team published a report of their novel technique last month in the journal Otolaryngology Head and Neck Surgery.
A new approach to a challenging procedure
Venous malformations are spaghetti-like, blood-filled clusters of unnecessary veins. They are usually present at birth and grow slowly, if at all, as a child grows. When they’re close to the skin, venous malformations look like a purplish mass.
But removing venous malformations is tough, explains Jonathan Perkins, DO, clinical chief of the Vascular Anomalies Program at Children’s. Although they are usually not dangerous, these vein clusters can be disfiguring and painful – and if one is accidentally bumped or cut, it can bleed profusely.
“These things are like water balloons filled with tiny tubes of liquid,” he says. “If we puncture one while we’re trying to remove it, it decompresses and there’s nothing left to remove.” When the puncture heals, the tube fills again with blood and the purplish mass can return.
Overcoming that obstacle by using glue was the brainchild of Basavaraj Ghodke, MB, BS, an interventional radiologist on the vascular anomalies team.
“Filling the veins with glue before operating seemed like a great solution,” recalls Perkins, who notes that n-BCA was designed to prevent strokes by treating leaking aneurysms in the brain. “You can inject it slowly and control where it goes, and it hardens up in about 20 minutes,” he says. “I thought, ‘why not try it?’”
When the glue is hard, the surgeon can clearly identify the boundaries of the malformation and cleanly remove it.
Puffy purple problem
Seven-year-old Kaleb Klempel of Eltopia, Wash. (a farm community four hours east of Seattle), was born with a venous malformation at the corner of his mouth.
“It looked like a big, puffy purple spot on the one side of his mouth,” says his dad, Reuel. “When he cried or got worked up, it would double or triple in size. We were concerned that if he fell or cut it somehow, that thing would really bleed.”
The Klempels, who have 12 children, knew and trusted Children’s (as a baby, Kaleb had orthopedic surgery here on his foot).When Kaleb was six, his parents were worried enough about the purple patch to travel here to have it checked out.
“When Dr. Perkins explained the super glue concept, it sounded to me like it might work,” says Reuel. “I knew doctors were using it in place of stitches because one of our other sons had a head wound treated with super glue at a hospital back east.”
The Klempels said “yes” to the experimental procedure.
Before: Choosing between imperfect options
Before they hit upon the glue concept, Perkins’ team was dissatisfied with the conventional treatments for venous malformations.
One option, sclerotherapy, involves injecting the veins with a substance that makes them shrink. “But this has to be done repeatedly, and each time under general anesthesia,” says Perkins. Recovery can be painful, and the substance can damage a patient’s skin or mucous membrane.
Even more troubling, the most effective sclerotherapy substance is absolute alcohol, which can potentially travel through the veins. “If the dose is big enough, it can stop the patient’s heart and even cause death,” he says. “That’s a big risk, and one we’re uncomfortable taking.”
A second option, he says, is “cooking” the malformed veins from the inside using a laser fiber. This, too, requires repeated procedures under general anesthesia and recovery is painful.
One procedure, three hours, less risk
Kaleb’s surgery started in the radiology suite, where an interventional radiologist injected the glue. By the time it set, the team had moved Kaleb to the operating room, where a surgeon removed the hardened chunk of glue – along with the rogue veins.
The entire procedure took about three hours, says Perkins.
To date, more than 20 Children’s patients with venous malformations in their mouths, heads, necks and cheeks have been treated with the glue procedure. When necessary, Perkins maps the facial nerve in ink on a patient’s skin to avoid damaging it during surgery.
The team has reviewed their patient cases dating to 2000, and they estimate that about half the patients Children’s treated for venous malformations since then would have benefited from the glue procedure, had it been available.
New standard of care
Kaleb spent one night in the hospital after his surgery. When his mouth healed there was no sign of the purplish mass, says Reuel. It has not returned in the year since his surgery.
The super glue procedure has already become the standard of care at Children’s for certain types of venous malformations in the head and neck, says Perkins. He hopes the paper in Otolaryngology Head and Neck Surgery will help spread the word of this ingenious procedure to peers at other institutions.
“It’s the first technique we’ve hit on that allows us to remove localized venous malformations in one shot – and with minimal risk of recurrence,” says Perkins.
If you’d like to arrange an interview with the Klempels or Drs. Perkins and Ghodke, please contact Children’s PR team at 206-987-4500 or at press@seattlechildrens.org.
I just want to say, as the mother of Kaleb, that I am super happy with the results. So is Kaleb. He was very self conscious about his lip because people always asked him how he had hurt himself. He was also experiencing pain when he cried because it would swell up so big. Now he has no more pain and only has a very little blue mark just above his lip. Also, applause for Doctor Perkins who did an excellent job taking time to explain to us all of our options! We felt very well informed as parents.
Karine – Thanks for your comment! We’re so glad to hear that Kaleb is doing well, and we’ll be sure to pass on your kind words to Dr. Perkins.
Hello:
This novel treatment does sound great–if only it could be applied to other limbs instead of just the face and so forth. I have venous malformations on my left leg and I’ve tried a couple of the different options. Treatment was definitely more effective when absolute alcohol was used. How risky is this treatment typically?
Thank you for reading about this new treatment and for your question. Dr. Perkins said that we have not used this treatment extensively in the extremities, so he can’t say how “risky” it is in this location. This would need to be determined on an individual basis for each specific malformation. In theory, he said, it could be used in the extremities.
My name is Nick Gavrilis and I live in Athens Greece. My sister suffers since birth by a low flow cavernous venous malformation to her lower right hand. She is now 33 years old. Can I contact Dr. Perkins directly to present details of this problem?Thank you.
Hi Nick – Thanks for your comment and for your interest in the new treatment for venous malformations. Dr. Perkins suggests sharing the information with your sister’s care team to see whether this new technique could be a possibility in her case.
I have a hemangioma on my lip and have been looking locally for a provider that treats adults. Do any of the providers on the vascular anomalies team at children’s also treat adults or do you know of any local providers that are familiar with this new procedure?
Hi Melissa – Thank you for the inquiry. I checked with our clinical team and learned that you have already been in contact with them, which is great news! Thank you again for reaching out to us.
I have a venous malformation on the right side of my face located mostly on the jaw. I was a patient of Dr. Perkins when I was younger I am now 25 years old. I was treated with scIerotherapy once. I recently read about the new treatment with glue I wanted to know how I can get treatment using that procedure. Is there anyone there that treats adults or somewhere that I can get referred to.
Thank you for your inquiry Vanessa. Our care team will be in touch with you shortly regarding setting up an appointment.
Hi, I have a venous malformation in my right cheek and am desperate to find a doc that can help. The last team of docs told me that my only option is to keep operating for the rest of my life. Keep cutting the branches off the tree but they will always grow back is what they told me. I would love a consultation please.
Thank you for the inquiry, Anna. I checked with our clinical team and learned that you have already been in contact with them, which is great news! Please let us know if we can be of more assistance.
Hi, I’m a 40 year old woman and have a massive venous malformation on my upper right leg/thigh area. It has literally taking over the whole area of the leg. I had sclerotherapy done twice which has help tremendously with the pain so I’m thankful for that but I’m wondering if this treatment could help my situation.
Hello,
I’m a 48 year old woman that has a venous malformation on the right side of my face. This runs from my right temple down to the jaw line. Have been told there is nothing to be done aside from sclerotherapy.
This new procedure sounds like is has tremendous possibilities as my malformation never deflates and causes pain and facial distortion.
I’m interested in contacting the clinical team even though I am an adult.
Thank you!
Thank you for your inquiries Karen and Mirlene. Since we don’t treat adults at Seattle Children’s, we are looking into this and will get back to you shortly.
Hi Karen and Mirlene – We are not aware of any other providers or hospitals offering this procedure at this time. Even though we’re a children’s hospital, we can see adult patients located in the Seattle area for a one time consultation. If interested, please call the Vascular Anomalies scheduling line 206-987-4606, option 1, to ask for an appointment. Patients should send or bring their most recent imaging (MRI or CT) to the consultation appointment. Thank you.
Could this be used on the tongue if the VM starts at the base of the tongue? I have a 14 year old that has had 14 yag laser treatments and would love this option.
Thank you Tracey for your inquiry. This is a great question for our medical team and feel free to call the Vascular Anomalies clinic at 206-987-4606.
Hi, my 10 year old daughter has a vascular malformation on her right cheek. She has had sclerotherapy done at the end of June 2014. I was hopeful, but unfortunately we will be doing another round of the treatment in March 2015. This procedure sounds like it could be a good treatment option that is less invasive and painful for her. How would I be able to pass this information onto the Radiologists at Children’s mercy in Kcmo? Thank you in advance!
Kristin
Hi Kristin – Thank you for reaching out to us. We recommend talking with your daughter’s doctor to see if it is a treatment option. For specific questions for our medical team, you can call our Vascular Anomalies clinic at 206-987-4606.
My daughter is 14 months old with a perineal vascular malformation. Is this something that might work on that area? We do NOT have a good team of doctors helping us yet. We are very concerned with getting her the right care with the best results.
Hi, I’ve had numerous surgeries on my left cheek when I was younger and none of them has worked. I’m 21 now, and would like to know where I can go to do this treatment since you don’t treat adults.
My daughter Ariel was born with a venous malformation on her cheek. shes had numerous laser surgeries done and has had two sclerotherapy procedures done through out her 7 years. She is going to have her third sclerotherapy procedure done. after reading about this procedure though im very interested in learning more. Please feel free to email me.
My mother is 65 and she has a venous malformation in the back of her neck. She has has 2 embolization injections and no relief. We live in Kansas City. She has had numerous tumors removed over the past 30+ years and recovered nicely but this one is painful. Is this glue option still available and something she could possibly benefit from?
My 10 year old son has a venous malformation in his right leg. I am extremely interested in if this would be something for him! How do I find out more?
My almost 15 year old son has a tongue venous malformation. The footprint of VM is roughly 3/4 of his tongue.
To date, he’s had 3 YAG laser surgeries and 3 sclerotherapy(doxycycline, ethanol and ethanol with endovascular laser). No lasting change has occurred. We are now considering a wedge resection surgery.
Would n-BCA glue be a viable option for him?
Thank you,
Chesna Adams
Hello. My 10 year old daughter Kaylee was born with a venous malformation on her lower lip. Will the n-BCA glue procedure can be worked on that area? I’m very interested in learning more about this super glue procedure. Please feel free to email me at hap7523@yahoo.com. We live in Dallas, TX. Thank you
Thank you Halena for your inquiry. This is a great question for our medical team and feel free to call the Vascular Anomalies clinic at 206-987-4606.
Hello,
My 16 year old daughter has had sclerotherapy 3x to treat a venous malformation in her right hip. Would the treatment featured in this article be an option for her?
Thank you Eric for your inquiry. This is a great question for our medical team and feel free to call the Vascular Anomalies clinic at 206-987-4606.
Hello,
My 25 year old son has a vascular malformation on his upper lip that has undergone the glue treatment at Mass General in Boston, Mass. It is 2 months later and it has shrunken a bit in size. He will now undergo the sclerotherapy (application of 2cc’s of absolute alcohol) along with the glue again in hopes to shrink the mass and also scar the tissue to prevent regrowth. He may need 2-3 sclerotherapy procedures to shrink the mass down to normalcy. We are hopeful!
My son Grady has a Cavernous hemangioma . He was treated when he was 2 years old with the embolization treatment in NYC by Milton Waner. He is now 14 years old and I am wondering can this growth grow back. Thank you for your help.
Thank you for reaching out. Please feel free to contact our Vascular Anomalies Program directly at 206-987-4606 with your question.