Vascular anomalies are classified as malformations or tumors. Depending on the vascular anomaly's location, extent, genetics, and effect on the patient, symptoms may be managed surgically, medically, using interventional means, or with all modalities. Surgical resection requires extreme care and diligence to ensure maximal resection and patient safety. Recent advancements in genetics and treatment agents have helped physicians provide targeted medical therapies.

Combined vascular malformations are complex, heterogeneous lesions increasingly classified by anatomic components and genetic drivers, specifically the PI3K/AKT/mTOR pathway (PROS) and RASA1 mutations. These syndromes, including Klippel-Trenaunay, CLOVES, and capillary malformation-arteriovenous malformation, present with soft-tissue hypertrophy, skeletal overgrowth, and varied vascular anomalies. Effective management requires a multidisciplinary approach to address complications such as thromboembolism, localized intravascular coagulopathy, and limb-length discrepancy. Diagnostic evaluation relies on ultrasound and MRI. Therapeutic interventions have evolved from conservative compression and sclerotherapy to targeted pharmacotherapy (sirolimus, alpelisib) and individualized surgical debulking, with the aim of improving functional outcomes and quality of life.

Arteriovenous malformations (AVMs)-lesions comprising abnormal communications between arteries and veins with no intervening capillary bed-are among the most challenging vascular anomalies to treat. Surgical resection may be highly morbid or impossible, but if left untreated lesions eventually progress to ulceration, bleeding, and in some cases heart failure. This review of extracranial AVMs covers epidemiology, etiology, pathogenesis including gene mutations associated with sporadic and syndromic AVM, clinical features, diagnosis, new and emerging medical treatments, and endovascular and surgical management of AVMs.

Venous malformations (VMs) are slow-flow vascular anomalies arising from hyperactivation of the TIE2-PI3K-AKT-mTOR pathway. This comprehensive review delineates the diverse clinical landscape of VMs, ranging from sporadic lesions to complex hereditary and syndromic phenotypes. We compile clinical characteristics of all VM subtypes. We detail diagnostic protocols and assessment for localized intravascular coagulopathy. Management requires a multidisciplinary approach, integrating conservative measures, sclerotherapy, surgery, and targeted medical therapies to optimize symptomatic relief and patient quality of life. We propose a treatment algorithm based on VM subtypes and affected tissue as well as different treatment combinations for staged management of complex cases.

Lymphatic malformations (LMs) are rare congenital vascular anomalies commonly affecting the cervicofacial region and frequently associated with somatic PIK3CA mutations. According to the 2025 International Society for the Study of Vascular Anomalies guidelines, LMs are classified into isolated lesions, complex anomalies, and lymphedemas. Diagnosis relies on ultrasound, MRI, and magnetic resonance lymphangiography for anatomic and functional evaluation. Management has evolved from primarily surgical excision to a multidisciplinary, multimodal strategy. Sclerotherapy and sirolimus now play central therapeutic roles, while surgery remains important for reconstruction and deformity correction. Emerging techniques such as bleomycin electrosclerotherapy and laser therapy further enhance individualized treatment outcomes.

Capillary malformation (CM), or port wine birthmark, is a congenital low-flow vascular malformation of dilated capillaries and postcapillary venules. It often affects the face and may darken, thicken, or develop nodules over time. Most CMs are isolated but can be associated with syndromes such as Sturge-Weber, characterized by a facial CM, leptomeningeal vascular malformation, and ocular findings such as glaucoma. CMs also occur in other syndromes, emphasizing the need for thorough clinical evaluation. Management is multidisciplinary, with pulsed-dye laser as the gold standard treatment; excision may be required for tissue overgrowth.

Infantile hemangioma (IH) is the most common benign soft tissue tumor of infancy with its pathogenesis yet to be elucidated. IHs are defined as vascular tumors of infancy and the diagnosis of IH is largely based on clinical findings, most commonly the characteristic strawberry appearance. IHs follow a stereotyped life cycle of rapid growth, a plateau, and eventual involution, and most do not require treatment. If complicated, first-line medical treatment of IH is oral propranolol, currently the most commonly used and efficacious drug. Surgery remains an option but is reserved for IHs primarily not responsive to medical treatment.

Surgical management of vascular anomalies depends on the type of lesion, location, symptoms, and consideration of other treatment options. A correct diagnosis must be confirmed before choosing management. Complete resection of a vascular anomaly rarely is required. Operative intervention should not cause a worse deformity than the lesion. Vascular anomalies primarily managed operatively include pyogenic granuloma, congenital hemangioma, and arteriovenous malformation. Resection of infantile hemangioma, kaposiform hemangioendothelioma, capillary malformation, lymphatic malformation, and venous malformation typically occurs after the lesion has been treated with other modalities (eg, medications, laser, sclerotherapy).

Most vascular anomalies are caused by mutations in the PI3K-AKT-mTOR or RAS-RAF-MEK-ERK signaling pathways. This knowledge, along with increasing availability of genetic testing for molecular diagnosis, has made medical management an important component of treatment of vascular anomalies. We are now able to use mTOR inhibitors like sirolimus, PI3K inhibitors like alpelisib and MEK inhibitors like trametinib for targeted therapy of vascular anomalies, often in conjunction with interventional and surgical management. Awareness of these treatment options can help provide optimal care to all patients with vascular anomalies.

This article reviews the evolving role of laser therapy in the management of vascular anomalies, emphasizing advances in selective photothermolysis, wavelength optimization, pulse modulation, and epidermal cooling that have improved treatment precision and safety. It outlines the principles of laser-tissue interaction and discusses how different laser systems, including pulsed dye laser, Nd:YAG, alexandrite laser, and IPL, are tailored to lesion depth and vascular characteristics. The article further examines lesion-specific management strategies for infantile hemangiomas and port-wine capillary malformations, highlighting indications, outcomes, limitations, and multimodal approaches. Emerging therapies such as photodynamic therapy are also discussed as promising options for resistant vascular lesions.

Vascular anomalies span a wide biological spectrum, from self-involuting infantile hemangiomas to life-threatening arteriovenous malformations. This review focuses on the conditions most commonly managed by interventional radiology, organized within the 2025 International Society for the Study of Vascular Anomalies classification framework. It covers the principles and agents of sclerotherapy for venous and lymphatic malformations, including comparative evidence for sclerosing agents, and embolization strategies for arteriovenous malformations and hereditary hemorrhagic telangiectasia -related pulmonary arteriovenous malformations. Also reviewed is the role of cryoablation in fibroadipose vascular anomaly, complex lymphatic anomaly management and the emerging techniques of bleomycin electrosclerotherapy and bleomycin electroembolotherapy.

Vascular anomalies are disorders of the endothelium affecting approximately 5% of the population. Lesions are divided into tumors and malformations. The most common tumors are infantile hemangioma, congenital hemangioma, kaposiform hemangioendothelioma, and pyogenic granuloma. The major types of malformations include capillary, lymphatic, venous, and arteriovenous. Vascular anomalies can have a similar appearance, but their natural history, morbidity, and prognosis are different. Before treating a vascular anomaly, its diagnosis must be confirmed. Diagnosis typically is made by history and physical examination. Imaging, histopathology, and genetic testing can aid diagnosis and management.

Pediatric lower extremity reconstruction, especially following trauma or oncologic resection, presents unique challenges requiring a multidisciplinary approach. Management emphasizes early, thorough debridement, appropriate fixation-often with flexible intramedullary nails-and timely, well-vascularized soft tissue coverage. Nerve injuries are addressed with autografts or allografts, with children demonstrating better regenerative capacity than adults. Postoperative protocols focus on immobilization, pain management, psychosocial support, and structured rehabilitation, with family involvement crucial for adherence. Microsurgeons are essential for complex reconstructions and addressing complications like critical limb ischemia. The field continues to evolve, prioritizing functional limb salvage and long-term quality of life for pediatric patients.