346 Letters
FEBRUARY 2009
REFERENCES
1. Bastarrika G, Redondo P, Sierra A, Cano D, Martı́nez-Cuesta A,
López-Gutiérrez JC, et al. New techniques for the evaluation
and therapeutic planning of patients with Klippel-Trénaunay
syndrome. J Am Acad Dermatol 2007;56:242-9.
2. Cohen MM. Klippel-Trénaunay syndrome. Am J Med Genet
2000;93:171-5.
3. Ziyeh S, Spreer J, Rössler J, Strecker R, Hochmuth A, Schu-
macher M, et al. Parkes Weber or Klippel-Trénaunay syndrome?
Non-invasive diagnosis with MR projection angiography. Eur
Radiol 2004;14:2025-9.
doi:10.1016/j.jaad.2008.09.044
Reply
To the Editor: In their letter, Li and Tian suggest that
multidetector row computed tomography (MDCT)
arteriography should be considered as the first step in
the endovascular management of KlippeleTrénaunay
syndrome (KTS). Their assumption is supported on
findings in a young patient in whom MDCT arteriog-
raphy and venography allowed the diagnosis of KTS.
This noninvasive technique permitted the differentia-
tion of KTS from other similar entities based on the
presence or absence of arteriovenous malformations.
In a previous manuscript,1 we concluded that
MDCT and three-dimensional magnetic resonance
(3D-MR) venography are extremely helpful for the
global evaluation and therapeutic planning of
patients with KTS. For this assessment, we analyzed
a cohort of patients with known KTS. In our study
population, these noninvasive tests were performed
with the main objective of delineating the location
and extent of venous malformations and determin-
ing patency of the deep venous system before
percutaneous schlerotherapy. Therefore, more
emphasis was placed on the usefulness of MDCT
and 3D-MR venography in detecting venous system
anomalies than in diagnosing KTS per se. In their
letter, Li and Tian propose the performance of MDCT
arteriography to diagnose KTS.
The role of noninvasive techniques for the assess-
ment of peripheral vascular malformations is under
continuous research. Both MDCT and magnetic
resonance angiography (MRA) provide high spatial
resolution volumetric imaging of vascular malforma-
tions. However, MDCT implies exposure to ionizing
radiation, and this fact may preclude its widespread
use, especially in younger patients. Moreover,
because patients with peripheral vascular malforma-
tions require follow-up studies, we consider mag-
netic resonance imaging to be a more suitable tool
for this purpose. In particular, dynamic MRA appears
to be valuable for assessing vascular malformations
of the extremities2 and distinguishing high- from
low-flow vascular malformations.3 While we agree
J AM ACAD DERMATOL
that MDCT arteriography could be used as a first step
technique for the diagnosis of KTS, we consider that
efforts in using noninvasive dynamic MRA would be
more beneficial for such a population.
On the other hand, Li and Tian propose the
performance of indirect MDCT venography for
patients with lymphedema. After our preliminary
experience, we now prefer indirect venography
to direct injection of contrast in lower extremity
veins to assess patency of the venous system. With an
adequate delay time of two to three minutes, this
approach allows us to delineate the anatomy and
extension of the entire vascular malformation while
depicting patency of the deep venous system in all
individuals.
MDCT arteriography may be a useful tool to
differentiate KTS from other mimicking entities.
However, taking into account the age of patients in
whom these exams are performed and the need of
further follow-up studies, we firmly believe that MRA
is the most suitable tool to make a correct diagnosis,
evaluate the extension, plan the therapy, and follow-
up on peripheral vascular malformations.
Gorka Bastarrika, PhD,a and Pedro Redondo,
PhDb
Departments of Radiologya and Dermatology,b
University Clinic of Navarra, Pamplona, Spain
Funding sources: None.
Conflicts of interest: None declared.
Correspondence to: Pedro Redondo, PhD, Depart-
ment of Dermatology, University Clinic of
Navarra, 31080 Pamplona, Spain
E-mail: predondo@unav.es
REFERENCES
1. Bastarrika G, Redondo P, Sierra A, Cano D, Martinez-Cuesta A,
López-Gutierrez JC, et al. New techniques for the evaluation
and therapeutic planning of patients with KlippeleTrénaunay
syndrome. J Am Acad Dermatol 2007;56:242-9.
2. Herborn CU, Goyen M, Lauenstein TC, Debatin JF, Ruehm SG,
Kroger K. Comprehensive time-resolved MRI of peripheral
vascular malformations. AJR Am J Roentgenol 2003;181:729-35.
3. Ohgiya Y, Hashimoto T, Gokan T, Watanabe S, Kuroda M, Hirose
M, et al. Dynamic MRI for distinguishing high-flow from low-
flow peripheral vascular malformations. AJR Am J Roentgenol
2005;185:1131-7.
doi:10.1016/j.jaad.2008.10.038
Skin manifestations of cocaine use
To the Editor: I read with interest the September
2008 article on the skin manifestations of cocaine
use by Brewer et al,1 and note that a readily