Imaging indications

An imaging diagnostic examination is indicated if a vascular anomaly cannot be clearly classified on the basis of medical history and physical examination alone or if therapy management is to be decided.

The aim of imaging is to determine the type of vascular anomaly and its differential diagnoses according to the ISSVA classification, to determine the extension of the vascular anomaly, to detect the secondary local and systemic effects of the vascular anomaly, and to detect or exclude accompanying anomalies. Imaging is also necessary for the planning and follow-up of invasive therapy.

Initially, it makes sense to start with sonography. It is simple, available everywhere, non-invasive and easy to use even in infants. If the diagnosis after sonography is still unclear or the extent of the vascular anomaly cannot be precisely determined, further imaging should be performed using contrast-enhanced magnetic resonance imaging (MRI). Computed tomography (CT) is generally suitable for imaging of bony structures and less so for soft tissue lesions. Contrast-enhanced CT angiography (CTA) plays a role in imaging of large vessels (e.g. the aorta or pulmonary arteries). Conventional radiographs are primarily used to visualize bones and joints in the case of orthopedic problems caused by the anomalies. Digital subtraction angiography (DSA) is still the gold standard in therapy planning and implementation of therapy for fast-flow vascular malformations, as it uses the flow of contrast medium to display hemodynamics with high spatial resolution. Phlebography/varicography is used during the therapy of venous malformations as well as lymphatic malformations and for assessment of the deep venous system.

In principle, in addition to the indications, the contraindications of the various imaging procedures must also be taken into account (e.g., contraindications for contrast media, certain metal implants, etc.). Imaging procedures based on the use of X-rays must be strictly indicated in view of the radiation exposure, especially in pediatric patients and during pregnancy.

If the results of clinical examination and imaging are contradictory, histologic confirmation should always be considered for further clarification (see Histopathology chapter).