Color Doppler Ultrasound Study of Glomuvenous Malformations with its Clinical and Histologic Correlations

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Wortsman, F. Millard, L. Aranibar" "autores" => array:3 [ 0 => array:4 [ "nombre" => "X." "apellidos" => "Wortsman" "email" => array:1 [ 0 => "xworts@yahoo.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Millard" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Aranibar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Imágenes, Instituto de Investigación y Diagnóstico por Imágenes en Piel y Tejidos Blandos, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermatología, Facultad de Medicina, Universidad de Chile, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecografía Doppler color en malformaciones glomuvenosas con correlación clínica e histológica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1849 "Ancho" => 3333 "Tamanyo" => 680519 ] ] "descripcion" => array:1 [ "en" => "A-B, Color Doppler spectral analysis showing single-phase venous vascularization in affected areas. C-F, Color Doppler spectral analysis showing two-phase (systolic and diastolic) arterial vascularization in affected areas." ] ] ] "textoCompleto" => "IntroductionGlomuvenous malformations (GVMs) are hamartomatous lesions characterized by the presence of glomus cells in the vascular smooth muscle.<a class="elsevierStyleCrossRef" href="#bib0055">1</a> Unlike most vascular malformations, histologic examination of GVMs reveals glomus cells. Unlike glomus tumors, histology does not show a hyperplastic or proliferative tumoral pattern of the glomus cells.<a class="elsevierStyleCrossRefs" href="#bib0055">1–4</a> The glomus cells correspond to modified smooth muscle cells surrounding arteriovenous anastomoses in the neuromyoarterial plexuses, which regulate blood flow and temperature.<a class="elsevierStyleCrossRefs" href="#bib0055">1,5</a>In more than 60% of cases, GVMs follow an autosomal dominant inheritance pattern. Diagnosis is based on clinical suspicion in the presence of blue or violaceous nodular or elongated structures that are sensitive to the touch, although to a lesser degree than glomus tumors. GVMs are often arranged linearly and sometimes have a dermatomal distribution.<a class="elsevierStyleCrossRefs" href="#bib0055">1,2</a>In recent years, a growing number of studies have demonstrated the utility of color Doppler ultrasound in the diagnosis of skin diseases, including vascular malformations and glomus tumors.<a class="elsevierStyleCrossRefs" href="#bib0080">6,7</a>We present the clinical and color Doppler ultrasound features of a series of 13 cases of histologically confirmed glomuvenous malformations (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All Doppler ultrasound studies were ordered by a physician after a dermatologic evaluation and carried out in accordance with the medical ethics principles of the Declaration of Helsinki.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Clinical EvaluationThirteen patients were evaluated (62% men and 38% women; mean [SD] age, 15 [18] years; range, 8-66 years). Bluish-violaceous nodules sensitive to the touch were present in all patients. Multiple segments (2 or more) were affected in 62% of patients and only 1 site was affected in 38% of patients. The number of body segments affected in each patient ranged from 1 to 5, with a mean of 2 segments affected per patient (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Ultrasound ExaminationAll patients were evaluated with color Doppler ultrasound with a compact high-frequency linear transducer (LOGIQ E9 XDclear, General Electric; maximum frequency 18MHz).The location (dermis or hypodermis), nature (solid, cystic, mixed), borders, echogenicity (hyperechoic, hypoechoic, anechoic), presence, type (arterial, venous, both), and flow velocity (cm/s) were described (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In all cases, color Doppler ultrasound study revealed moderately delimited superficial dermal and hypodermal pseudonodular structures of mixed echogenicity, with hypoechoic and heterogeneous areas and anechoic, pseudocystic tubular and lacunar zones. Arterial and venous vessels, mainly with low-flow (≤ 15cm/s), were observed in 85% of patients, but no arteriovenous shunts were present. Deeper structures were not affected and no phleboliths were detected (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Histologic ExaminationIn all cases, histologic examination revealed lesions composed of congestive blood vessels lined by a typical thin endothelium and surrounded by cells with a glomus appearance. Immunohistochemistry was positive for actin and negative for desmin.DiscussionClinical diagnosis of GVM can be challenging. The use of ultrasound can help to clarify the diagnosis. More than 80% of patients with glomus tumors initially receive an incorrect clinical diagnosis, with a mean duration of 14 years from onset of symptoms to correct diagnosis.<a class="elsevierStyleCrossRef" href="#bib0090">8</a>Although GVM could be considered a variant of glomus tumor or venous vascular malformation, the combination of clinical, sonographic, and histologic data and the presence of multiple, congenital, linearly distributed, sensitive but not highly painful lesions suggests a different entity.In an ultrasound study, GVM is differentiated from glomus tumors by the absence of well-defined hypoechoic nodular formations, which are characteristic of intra- and extradigital glomus tumors.<a class="elsevierStyleCrossRefs" href="#bib0080">6,9</a>Sonographic differential diagnosis with arteriovenous vascular malformations is possible because spectral analysis in GVM usually does not show arterialized venous flow-through suggestive of arteriovenous communications or flow velocities>15cm/s.GVM is distinguished from venous vascular malformations by the presence of low-flow arterial vessels with concomitant venous vascular structures.The frequent finding of low arterial and venous flow in GVM suggests that glomuvenous is not the most accurate term, as it does not reflect the arterial component of this entity. A less confusing and more anatomically correct name would be glomus vascular malformation.The utility of ultrasound in the study of GVM is limited by the sensitivity of the ultrasound equipment currently available, which is capable of detecting flow velocities of ≥ 2cm/s. Therefore, vessels with capillary, slow, or ectatic flow would not be perceptible in color Doppler spectral analysis.Moreover, color Doppler ultrasound can help to rule out subclinical foci of lesions and areas of intralesional thrombosis and to detect and define the lesion's precise location, extent, and relationship with adjacent structures, which can be helpful if surgical intervention is necessary.<a class="elsevierStyleCrossRefs" href="#bib0080">6,7</a>However, the use of color Doppler ultrasound in dermatology requires training in the operation of the equipment, a constant practice, and the use of a standardized protocol.<a class="elsevierStyleCrossRef" href="#bib0100">10</a>In conclusion, clinical-sonographic correlation could help to improve diagnostic accuracy in GVM and assist in surgical planning or noninvasive follow-up.Ethical DisclosuresProtection of persons and animals. The authors declare that no experiments were performed on humans or animals for the purpose of this study.Data confidentiality. The authors declare that they followed their hospital's regulations regarding the publication of patient information.Right to privacy and informed consent. The authors declare that no private patient data appear in this article.Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1011125" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec970518" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1011126" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec970519" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Evaluation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Ultrasound Examination" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Histologic Examination" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical Disclosures" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec970518" "palabras" => array:5 [ 0 => "Glomuvenous malformation ultrasound" 1 => "Glomangioma ultrasound" 2 => "Dermatologic ultrasound" 3 => "Skin ultrasound" 4 => "Vascular malformations" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec970519" "palabras" => array:5 [ 0 => "Malformación glomuvenosa ecografía" 1 => "Glomangioma ecografía" 2 => "Ultrasonido dermatológico" 3 => "Ultrasonido piel" 4 => "Malformaciones vasculares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Glomuvenous malformations are hamartomatous lesions characterized by the presence of glomus cells in the vascular smooth muscle. We present the clinical and color Doppler ultrasound features of a series of 13 cases of histologically confirmed glomuvenous malformations. In all cases, the ultrasound study revealed moderately delimited superficial dermal and hypodermal pseudonodular structures of mixed echogenicity, with hypoechoic and heterogeneous areas and anechoic, pseudocystic tubular and lacunar zones. Arterial and venous vessels, mainly with a low flow (≤ 15cm/s) were observed in 85% of patients, but no arteriovenous shunts were present. Deeper structures were not affected and no phleboliths were detected. The clinical and ultrasound findings could facilitate diagnosis, surgical planning, and noninvasive follow-up in these tumors." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las malformaciones glomuvenosas son hamartomas originados por la presencia de células glómicas en el músculo liso de las estructuras vasculares. Presentamos una serie de 13 casos de malformaciones glomuvenosas evaluadas clínicamente, estudiadas con ecotomografía Doppler color y confirmadas histológicamente. En las ecografías se observaron en todos los casos formaciones dérmicas e hipodérmicas superficiales, moderadamente delimitadas, de ecoestructura mixta, pseudonodulares, hipoecogénicas y heterogéneas con áreas tubulares y lacunares anecogénicas pseudoquísticas. El 85% de los casos demostró presencia de vasos arteriales y venosos, con predominio de los de baja velocidad (≤ 15cm/s) sin shunts arteriovenosos. No se visualizó compromiso de estructuras profundas ni flebolitos.Los hallazgos clínicos y ecográficos podrían ayudar a precisar mejor el diagnóstico, la planificación quirúrgica o el seguimiento no invasivo en estas entidades." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Wortsman X, Millard F, Aranibar L. Ecografía Doppler color en malformaciones glomuvenosas con correlación clínica e histológica. Actas Dermosifiliogr. 2018;109:e17–e21." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1139 "Ancho" => 2333 "Tamanyo" => 412468 ] ] "descripcion" => array:1 [ "en" => "A-E, Clinical presentations of glomuvenous malformations. Bluish or violaceous papules and nodules, some with a linear and dermatomal distribution." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1662 "Ancho" => 2917 "Tamanyo" => 464407 ] ] "descripcion" => array:1 [ "en" => "A-F, Color Doppler ultrasound images showing the sonographic appearance of glomuvenous malformations, with dermal and hypodermal pseudonodular formations of mixed echogenicity, with hypoechoic areas and anechoic lacunar and tubular zones with variable vascularization." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1849 "Ancho" => 3333 "Tamanyo" => 680519 ] ] "descripcion" => array:1 [ "en" => "A-B, Color Doppler spectral analysis showing single-phase venous vascularization in affected areas. C-F, Color Doppler spectral analysis showing two-phase (systolic and diastolic) arterial vascularization in affected areas." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: F, female; M, male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Segments \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Involvement \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Flow \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Flow Rate, cm/s \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hand and foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thigh and leg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lower back \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Heel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arm, forearm, costal region, dorsal region, knee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Periumbilical area, arm, forearms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thigh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anterior abdominal wall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arm, thigh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dorsal region, lower back \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arterial and venous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1712393.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and Sonographic Characteristics." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Glomuvenous malformations with smooth muscle and eccrine glands: Unusual histopathologic features in a familial setting" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. 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e-Case Report

Color Doppler Ultrasound Study of Glomuvenous Malformations with its Clinical and Histologic Correlations

Ecografía Doppler color en malformaciones glomuvenosas con correlación clínica e histológica

X. Wortsmana,b,

Corresponding author

xworts@yahoo.com

Corresponding author.

, F. Millardb, L. Aranibarb

a Departamento de Imágenes, Instituto de Investigación y Diagnóstico por Imágenes en Piel y Tejidos Blandos, Santiago, Chile

b Departamento de Dermatología, Facultad de Medicina, Universidad de Chile, Santiago, Chile

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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A-B&#44; Color Doppler spectral analysis showing single-phase venous vascularization in affected areas&#46; C-F&#44; Color Doppler spectral analysis showing two-phase &#40;systolic and diastolic&#41; arterial vascularization in affected areas&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Glomuvenous malformations &#40;GVMs&#41; are hamartomatous lesions characterized by the presence of glomus cells in the vascular smooth muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Unlike most vascular malformations&#44; histologic examination of GVMs reveals glomus cells&#46; Unlike glomus tumors&#44; histology does not show a hyperplastic or proliferative tumoral pattern of the glomus cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;4</span></a> The glomus cells correspond to modified smooth muscle cells surrounding arteriovenous anastomoses in the neuromyoarterial plexuses&#44; which regulate blood flow and temperature&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In more than 60&#37; of cases&#44; GVMs follow an autosomal dominant inheritance pattern&#46; Diagnosis is based on clinical suspicion in the presence of blue or violaceous nodular or elongated structures that are sensitive to the touch&#44; although to a lesser degree than glomus tumors&#46; GVMs are often arranged linearly and sometimes have a dermatomal distribution&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years&#44; a growing number of studies have demonstrated the utility of color Doppler ultrasound in the diagnosis of skin diseases&#44; including vascular malformations and glomus tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the clinical and color Doppler ultrasound features of a series of 13 cases of histologically confirmed glomuvenous malformations &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; All Doppler ultrasound studies were ordered by a physician after a dermatologic evaluation and carried out in accordance with the medical ethics principles of the Declaration of Helsinki&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Evaluation</span><p id="par0025" class="elsevierStylePara elsevierViewall">Thirteen patients were evaluated &#40;62&#37; men and 38&#37; women&#59; mean &#91;SD&#93; age&#44; 15 &#91;18&#93; years&#59; range&#44; 8-66 years&#41;&#46; Bluish-violaceous nodules sensitive to the touch were present in all patients&#46; Multiple segments &#40;2 or more&#41; were affected in 62&#37; of patients and only 1 site was affected in 38&#37; of patients&#46; The number of body segments affected in each patient ranged from 1 to 5&#44; with a mean of 2 segments affected per patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ultrasound Examination</span><p id="par0030" class="elsevierStylePara elsevierViewall">All patients were evaluated with color Doppler ultrasound with a compact high-frequency linear transducer &#40;LOGIQ E9 XDclear&#44; General Electric&#59; maximum frequency 18<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The location &#40;dermis or hypodermis&#41;&#44; nature &#40;solid&#44; cystic&#44; mixed&#41;&#44; borders&#44; echogenicity &#40;hyperechoic&#44; hypoechoic&#44; anechoic&#41;&#44; presence&#44; type &#40;arterial&#44; venous&#44; both&#41;&#44; and flow velocity &#40;cm&#47;s&#41; were described &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In all cases&#44; color Doppler ultrasound study revealed moderately delimited superficial dermal and hypodermal pseudonodular structures of mixed echogenicity&#44; with hypoechoic and heterogeneous areas and anechoic&#44; pseudocystic tubular and lacunar zones&#46; Arterial and venous vessels&#44; mainly with low-flow &#40;&#8804;&#160;15<span class="elsevierStyleHsp" style=""></span>cm&#47;s&#41;&#44; were observed in 85&#37; of patients&#44; but no arteriovenous shunts were present&#46; Deeper structures were not affected and no phleboliths were detected &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Histologic Examination</span><p id="par0040" class="elsevierStylePara elsevierViewall">In all cases&#44; histologic examination revealed lesions composed of congestive blood vessels lined by a typical thin endothelium and surrounded by cells with a glomus appearance&#46; Immunohistochemistry was positive for actin and negative for desmin&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Clinical diagnosis of GVM can be challenging&#46; The use of ultrasound can help to clarify the diagnosis&#46; More than 80&#37; of patients with glomus tumors initially receive an incorrect clinical diagnosis&#44; with a mean duration of 14 years from onset of symptoms to correct diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Although GVM could be considered a variant of glomus tumor or venous vascular malformation&#44; the combination of clinical&#44; sonographic&#44; and histologic data and the presence of multiple&#44; congenital&#44; linearly distributed&#44; sensitive but not highly painful lesions suggests a different entity&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In an ultrasound study&#44; GVM is differentiated from glomus tumors by the absence of well-defined hypoechoic nodular formations&#44; which are characteristic of intra- and extradigital glomus tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Sonographic differential diagnosis with arteriovenous vascular malformations is possible because spectral analysis in GVM usually does not show arterialized venous flow-through suggestive of arteriovenous communications or flow velocities<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>cm&#47;s&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">GVM is distinguished from venous vascular malformations by the presence of low-flow arterial vessels with concomitant venous vascular structures&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The frequent finding of low arterial and venous flow in GVM suggests that <span class="elsevierStyleItalic">glomuvenous</span> is not the most accurate term&#44; as it does not reflect the arterial component of this entity&#46; A less confusing and more anatomically correct name would be <span class="elsevierStyleItalic">glomus vascular malformation</span>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The utility of ultrasound in the study of GVM is limited by the sensitivity of the ultrasound equipment currently available&#44; which is capable of detecting flow velocities of &#8805;&#160;2<span class="elsevierStyleHsp" style=""></span>cm&#47;s&#46; Therefore&#44; vessels with capillary&#44; slow&#44; or ectatic flow would not be perceptible in color Doppler spectral analysis&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Moreover&#44; color Doppler ultrasound can help to rule out subclinical foci of lesions and areas of intralesional thrombosis and to detect and define the lesion&#39;s precise location&#44; extent&#44; and relationship with adjacent structures&#44; which can be helpful if surgical intervention is necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">However&#44; the use of color Doppler ultrasound in dermatology requires training in the operation of the equipment&#44; a constant practice&#44; and the use of a standardized protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion&#44; clinical-sonographic correlation could help to improve diagnostic accuracy in GVM and assist in surgical planning or noninvasive follow-up&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of persons and animals</span>&#46; The authors declare that no experiments were performed on humans or animals for the purpose of this study&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Data confidentiality</span>&#46; The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent</span>&#46; The authors declare that no private patient data appear in this article&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Malformaci&#243;n glomuvenosa ecograf&#237;a"
            1 => "Glomangioma ecograf&#237;a"
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            3 => "Ultrasonido piel"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Glomuvenous malformations are hamartomatous lesions characterized by the presence of glomus cells in the vascular smooth muscle&#46; We present the clinical and color Doppler ultrasound features of a series of 13 cases of histologically confirmed glomuvenous malformations&#46; In all cases&#44; the ultrasound study revealed moderately delimited superficial dermal and hypodermal pseudonodular structures of mixed echogenicity&#44; with hypoechoic and heterogeneous areas and anechoic&#44; pseudocystic tubular and lacunar zones&#46; Arterial and venous vessels&#44; mainly with a low flow &#40;&#8804; 15<span class="elsevierStyleHsp" style=""></span>cm&#47;s&#41; were observed in 85&#37; of patients&#44; but no arteriovenous shunts were present&#46; Deeper structures were not affected and no phleboliths were detected&#46; The clinical and ultrasound findings could facilitate diagnosis&#44; surgical planning&#44; and noninvasive follow-up in these tumors&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las malformaciones glomuvenosas son hamartomas originados por la presencia de c&#233;lulas gl&#243;micas en el m&#250;sculo liso de las estructuras vasculares&#46; Presentamos una serie de 13 casos de malformaciones glomuvenosas evaluadas cl&#237;nicamente&#44; estudiadas con ecotomograf&#237;a Doppler color y confirmadas histol&#243;gicamente&#46; En las ecograf&#237;as se observaron en todos los casos formaciones d&#233;rmicas e hipod&#233;rmicas superficiales&#44; moderadamente delimitadas&#44; de ecoestructura mixta&#44; pseudonodulares&#44; hipoecog&#233;nicas y heterog&#233;neas con &#225;reas tubulares y lacunares anecog&#233;nicas pseudoqu&#237;sticas&#46; El 85&#37; de los casos demostr&#243; presencia de vasos arteriales y venosos&#44; con predominio de los de baja velocidad &#40;&#8804; 15<span class="elsevierStyleHsp" style=""></span>cm&#47;s&#41; sin <span class="elsevierStyleItalic">shunts</span> arteriovenosos&#46; No se visualiz&#243; compromiso de estructuras profundas ni flebolitos&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los hallazgos cl&#237;nicos y ecogr&#225;ficos podr&#237;an ayudar a precisar mejor el diagn&#243;stico&#44; la planificaci&#243;n quir&#250;rgica o el seguimiento no invasivo en estas entidades&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Wortsman X&#44; Millard F&#44; Aranibar L&#46; Ecograf&#237;a Doppler color en malformaciones glomuvenosas con correlaci&#243;n cl&#237;nica e histol&#243;gica&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;e17&#8211;e21&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A-E&#44; Clinical presentations of glomuvenous malformations&#46; Bluish or violaceous papules and nodules&#44; some with a linear and dermatomal distribution&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A-F&#44; Color Doppler ultrasound images showing the sonographic appearance of glomuvenous malformations&#44; with dermal and hypodermal pseudonodular formations of mixed echogenicity&#44; with hypoechoic areas and anechoic lacunar and tubular zones with variable vascularization&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A-B&#44; Color Doppler spectral analysis showing single-phase venous vascularization in affected areas&#46; C-F&#44; Color Doppler spectral analysis showing two-phase &#40;systolic and diastolic&#41; arterial vascularization in affected areas&#46;</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; F&#44; female&#59; M&#44; male&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&#44; y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of Segments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Flow Rate&#44; cm&#47;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hand and foot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thigh and leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lower back&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arm&#44; forearm&#44; costal region&#44; dorsal region&#44; knee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Foot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Periumbilical area&#44; arm&#44; forearms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thigh&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anterior abdominal wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arm&#44; thigh&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Forearm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dorsal region&#44; lower back&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial and venous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical and Sonographic Characteristics&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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                      "Revista" => array:6 [
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Article information

ISSN: 15782190
Original language: English

DOI:10.1016/j.adengl.2018.02.004

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	7	12	19
2024 October	93	38	131
2024 September	99	20	119
2024 August	129	60	189
2024 July	95	36	131
2024 June	90	30	120
2024 May	77	38	115
2024 April	93	46	139
2024 March	87	31	118
2024 February	92	44	136
2024 January	90	29	119
2023 December	94	30	124
2023 November	97	30	127
2023 October	80	25	105
2023 September	80	36	116
2023 August	65	21	86
2023 July	94	55	149
2023 June	103	30	133
2023 May	110	32	142
2023 April	101	40	141
2023 March	109	49	158
2023 February	91	24	115
2023 January	82	49	131
2022 December	80	46	126
2022 November	34	31	65
2022 October	45	30	75
2022 September	37	54	91
2022 August	38	36	74
2022 July	24	47	71
2022 June	24	30	54
2022 May	92	59	151
2022 April	104	45	149
2022 March	110	71	181
2022 February	112	45	157
2022 January	136	60	196
2021 December	95	51	146
2021 November	72	73	145
2021 October	86	68	154
2021 September	70	54	124
2021 August	55	68	123
2021 July	50	46	96
2021 June	53	52	105
2021 May	63	58	121
2021 April	189	109	298
2021 March	99	59	158
2021 February	80	52	132
2021 January	77	50	127
2020 December	58	44	102
2020 November	39	37	76
2020 October	30	14	44
2020 September	48	30	78
2020 August	38	25	63
2020 July	34	27	61
2020 June	39	42	81
2020 May	43	11	54
2020 April	44	22	66
2020 March	28	12	40
2020 February	3	0	3
2020 January	2	0	2
2019 December	8	0	8
2019 November	4	0	4
2019 September	10	0	10
2019 August	4	0	4
2019 July	4	0	4
2019 June	4	0	4
2019 May	6	0	6
2019 April	2	0	2
2019 March	2	0	2
2019 February	2	0	2
2018 December	2	0	2
2018 November	3	0	3
2018 October	1	2	3
2018 September	2	0	2
2018 April	2	0	2

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