Imaging the invisible: Paediatric venous malformation of the ankle with DSA confirmation

Shirlin M.S1*, Vignesh. R1, Johnson A2

1Clinical Pharmacist, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

2Group Clinical Pharmacist, Kauvery Hospital, Trichy, Tamil Nadu

*Correspondence

Abstract

Venous malformations are congenital low-flow vascular anomalies that may present in childhood with pain, swelling, and functional impairment. We report a case of a 9-year-old female child presenting with chronic right ankle pain and swelling following minor trauma. Initial conservative management was unsuccessful. Multimodal imaging including ultrasound, CT angiography, MRI angiography, and digital subtraction angiography (DSA) confirmed the diagnosis of a low-flow venous malformation involving the posterior and medial aspect of the right ankle, deep to the Achilles tendon. This case highlights the importance of comprehensive imaging in accurate lesion characterization and differentiation from high-flow vascular malformations.

Keywords: Venous malformation; Digital subtraction angiography.

Introduction

Vascular malformations are congenital anomalies resulting from abnormal vascular morphogenesis. They are classified into low-flow lesions (venous, lymphatic, and capillary) and high-flow lesions (arteriovenous malformations). Venous malformations are the most common low-flow subtype and typically present with pain, swelling, and functional limitation in childhood or adolescence.

Case Presentation

A 9-year-old female child presented with persistent pain and swelling of the right ankle for one year. Symptoms began following minor trauma to the right lower limb. Initial management included topical ointments and hot fomentation; however, symptoms persisted with gradual progression, leading to difficulty in ambulation.

Clinical examination revealed swelling over the medial and posterior aspect of the right ankle with tenderness and pain on walking. No skin ulceration or discoloration was noted.

Investigations

Ultrasound (USG) Ankle revealed ill-defined hyperechoic lesion measuring 2.5 × 1.2 cm in the medial ankle region. Minimal internal vascularity on Doppler study. Suggestive of vascular malformation.

CT Angiography (Lower Limb) revealed multiple dilated serpiginous venous channels in the medial aspect of the distal third of the leg and ankle. Early venous filling with contrast pooling. No arterial feeders identified. Impression: Low-flow venous malformation.

MRI Angiography revealed lobulated lesion in the posterior ankle region at retrocalcaneal location, deep to the Achilles tendon. T2/STIR hyperintense and T1 isointense lesion. Multiple serpiginous vascular channels with intense post-contrast enhancement. Impression: Venous malformation.

Digital Subtraction Angiography (DSA) revealed Low-flow vascular lesion involving the right ankle region. Faint and delayed contrast opacification. No evidence of arteriovenous shunting which confirmed low-flow venous malformation.

Digital Subtraction Angiography (DSA) is an invasive fluoroscopic vascular imaging technique that utilizes pre-contrast and post-contrast image acquisition with digital subtraction of background structures to enhance visualization of the vascular lumen. It provides high spatial and temporal resolution with real-time assessment of vascular anatomy and hemodynamic. DSA is the gold standard for evaluation of cerebrovascular and peripheral vascular pathologies, including aneurysms, arteriovenous and venous malformations, and arterial stenosis or occlusion, and it is widely used for planning and guiding endovascular interventions such as embolization, stent deployment, and management of acute hemorrhage.

Advantages include high-resolution, real-time vascular imaging, precise assessment of vascular anatomy and flow dynamics, superior visualization of small and complex vascular networks, capability for selective and super selective catheterization, and the ability to combine diagnosis with therapeutic intervention in a single setting.

Risks / Complications of DSA

Exposure to ionizing radiation can cause contrast-related reactions (allergic or anaphylactoid), Contrast-induced nephropathy (in susceptible patients), access site complications like hematoma, bleeding, bruising and pseudoaneurysm (rare), vascular injury (dissection or perforation (rare), thromboembolic events (rare) and local infection at puncture site (uncommon)

Diagnosis

Low-flow venous malformation involving the posterior and medial aspect of the right ankle, deep to the Achilles tendon.

Discussion

Venous malformations are congenital vascular anomalies characterized by dysplastic venous channels with slow-flow hemodynamic. They often present in childhood and may be mistaken for post-traumatic or inflammatory conditions, leading to delayed diagnosis.

In this case, the initial presentation following minor trauma led to conservative management and delayed definitive diagnosis. Ultrasound suggested a vascular lesion, while CT angiography and MRI provided detailed anatomical and structural characterization. MRI demonstrated typical T2 / STIR hyperintensity with serpiginous vascular channels and intense post-contrast enhancement.

DSA confirmed the low-flow nature of the lesion and excluded arteriovenous shunting, which is essential for accurate classification and treatment planning. Multimodal imaging is crucial in differentiating venous malformations from high-flow arteriovenous malformations, as management strategies differ significantly.

Conclusion

This case highlights a paediatric low-flow venous malformation of the ankle presenting with chronic pain and swelling. Comprehensive multimodal imaging, including DSA, is essential for accurate diagnosis, exclusion of high-flow lesions, and appropriate management planning. Early recognition can prevent misdiagnosis and facilitate optimal therapeutic intervention.

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