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\begin{document}

\title{Assessing coagulopathy and endothelial dysfunction in paediatric venous
malformation: A thromboelastometry and syndecan-1 study}



\author[1]{Francisco Nava y Hurtado}%
\author[1]{Elena Monzon Manzano}%
\author[2]{Vanesa Viana-Huete}%
\author[1]{Paloma Triana}%
\author[1]{Maria Teresa Alvarez-Roman}%
\author[1]{Elena G. Arias-Salgado}%
\author[1]{Nora Butta}%
\author[1]{Juan Carlos Lopez-Gutierrez}%
\affil[1]{Hospital Universitario La Paz}%
\affil[2]{Universidad Europea Facultad de Ciencias Biomedicas y de la Salud}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective (69) The occurrence of unpredictable pain crises are the
principal determinant of the quality of life for patients with venous
malformations (VM). A definite coagulation phenomenon, characterized by
an increase in D-dimer levels and the presence of phleboliths within the
malformation, has been previously reported. By applying Virchow's triad
and evaluating intralesional samples, our objective is to delineate the
coagulation profile and the extent of endothelial dysfunction within the
malformation. Methods (42) With the authorization of the Ethics
Committee, a research project was undertaken on intralesional and
extralesional blood samples from 30 pediatric patients afflicted with
spongiform VM. Thromboelastometry analyses were performed using ROTEM
\selectlanguage{ngerman}\textsuperscript{®} Sigma, and the concentration of syndecan-1 was
determined by ELISA. Results (80) In the ROTEM \textsuperscript{®}
analyses, the A5, A10, and MCF values were below the established
reference ranges in the intralesional samples in both the EXTEM and
INTEM assays indicating that intralesional clots had significant
instability. Furthermore, during the investigation of the delayed
fibrinolysis phase using recombinant tissue plasminogen activator (rtPA)
in EXTEM analysis, widespread hyperfibrinolysis was observed
intralesional. Additionally, analysis of syndecan-1 showed significant
differences between extralesional and intralesional levels
(p\textless{}0.026) and controls (p\textless{}0.03), suggesting
differences in the state of endothelium. Conclusions (39) For the first
time, we developed a comprehensive understanding of the coagulopathic
profile of VM and the role of endothelial dysfunction in its
pathogenesis. These findings will enable the implementation of targeted
therapies based on the individual coagulation profiles.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Assessing coagulopathy and endothelial dysfunction in paediatric
venous malformation: A thromboelastometry and syndecan-1 study}
Francisco Nava y Hurtado\textsuperscript{a},MD, Elena Monzon
Manzano\textsuperscript{b,c}, PhD, Vanesa
Viana-Huete\textsuperscript{d}, PhD, Paloma Triana
Junco\textsuperscript{a}, MD, PhD, Maria Teresa
Alvarez-Roman\textsuperscript{b,c}, MD, PhD, Elena G.
Arias-Salgado\textsuperscript{b,c}, PhD, Nora
Butta\textsuperscript{b,c}, PhD, Juan Carlos Lopez
Gutierrez\textsuperscript{a,c}, MD, PhD.\textbf{Affiliations:}
aDepartment of Paediatric Surgery, Hospital Universitario La Paz,
Madrid. \textsuperscript{b} Department of Haematology, Hospital
Universitario La Paz, Madrid, Spain.\textsuperscript{c} IdiPAZ, Madrid,
Spain, \textsuperscript{d}Department of Health~Sciences. Universidad
Europea de Madrid\textbf{Address correspondence to}: Francisco Nava y
Hurtado, Department of Paediatric Surgery, Hospital Universitario La
Paz, Edificio Infantil, 1\selectlanguage{ngerman}º planta; Paseo de la Castellana 261 - 28046
Madrid, Spain

Email: franciscodeborja.nava@salud.madrid.org

Phone: (+34) 91 727 70 19

\textbf{Word Count:}

Abstract: 230

Main text: 2148

Tables: 4

Figures: 1

\textbf{Short title:} Coagulopathy and endothelial dysfunction in
paediatric venous malformation\textbf{Keywords:} Coagulopathy, venous
malformation, intralesional, ROTEM\textsuperscript{®}, syndecan-1,
glycocalyx.\textbf{Abbreviations:} Venous malformations (VM), syndecan-1
(SDC-1), localised intralesional coagulopathy (LIC), disseminated
intravascular coagulopathy (DIC), clotting time (CT), clot formation
time (CFT), maximum clot firmness (MCF), clot amplitude at 5 and 10
minutes after CT (A5 and A10), recombinant tissue plasminogen activator
(tPA)

Objective (69)

The occurrence of unpredictable pain crises are the principal
determinant of the quality of life for patients with venous
malformations (VM). A definite coagulation phenomenon, characterized by
an increase in D-dimer levels and the presence of phleboliths within the
malformation, has been previously reported. By applying Virchow's triad
and evaluating intralesional samples, our objective is to delineate the
coagulation profile and the extent of endothelial dysfunction within the
malformation.

Methods (42)

With the authorization of the Ethics Committee, a research project was
undertaken on intralesional and extralesional blood samples from 30
pediatric patients afflicted with spongiform VM. Thromboelastometry
analyses were performed using ROTEM\textsuperscript{®} Sigma, and the
concentration of syndecan-1 was determined by ELISA.

Results (80)

In the ROTEM\textsuperscript{®} analyses, the A5, A10, and MCF values
were below the established reference ranges in the intralesional samples
in both the EXTEM and INTEM assays indicating that intralesional clots
had significant instability. Furthermore, during the investigation of
the delayed fibrinolysis phase using recombinant tissue plasminogen
activator (rtPA) in EXTEM analysis, widespread hyperfibrinolysis was
observed intralesional. Additionally, analysis of syndecan-1 showed
significant differences between extralesional and intralesional levels
(p\textless{}0.026) and controls (p\textless{}0.03), suggesting
differences in the state of endothelium.

Conclusions (39)

For the first time, we developed a comprehensive understanding of the
coagulopathic profile of VM and the role of endothelial dysfunction in
its pathogenesis. These findings will enable the implementation of
targeted therapies based on the individual coagulation profiles.

Introduction (352)

Venous malformations (VM) are vascular anomalies, affecting 1\% of the
general population, characterized by venous dilatations of dysplastic
veins, leading to an increased risk of thrombosis. This condition can
result in elevated D-dimer levels in extralesional blood, known as
localised intralesional coagulopathy (LIC) .In some cases, a decrease in
fibrinogen levels may precede the development of disseminated
intravascular coagulopathy (DIC) , although very few cases have been
described in the literature. Asymptomatic lesions are common, but they
may cause unpredictable pain crises, mostly due to exacerbation of LIC.
The emotional distress caused by these episodes can lead to a lower
quality of life for patients affected by VM compared with the general
population .

To date the most significant discoveries for advancing treatment of
patients affected by VM was the identification of a collection of
mutated genes and their clinical impact in cellular models .These
advances have enabled the application of targeted therapies that inhibit
hyperfunctioning signalling pathways, such as sirolimus and mTOR
proteins , alpelisib and PIK3CA proteins , and rebastinib and TIE
receptors . Despite the identification of the initial genetic error,
thrombosis phenomena are still based on Virchow's classical triad. In
this regard, different research groups have analysed conventional
coagulation parameters using extralesional blood samples although the
use of new tools for a more complete analysis of the clot-formation
process has recently been reported .Viscoelastic tests allow us to
quickly identify the function of different elements involved in
coagulation and fibrinolysis processes, which has popularised their use
in situations that require rapid response .

Recently, glycocalyx impairment has been linked to several diseases with
significant social impacts involving endothelial dysfunction .This
structure, which contains glycosaminoglycans and glycoproteins, mediates
various physiological processes, such as angiogenesis , vascular
permeability , and coagulation .

To investigate coagulopathic phenomena and endothelial dysfunction in
paediatric patients with venous malformations, we conducted
thromboelastometry studies using ROTEM\textsuperscript{®} technology
(Tem GmBH; Munich, Bavaria, Germany). Additionally, we analysed the
intralesional coagulation system and investigated the degree of
endothelial dysfunction as a function of syndecan-1 glycoprotein levels.

Methods (547)

\emph{Patients and study design}

This was an observational, prospective and transversal study approved by
the local Research Ethics Committee (PI-5557). Paediatric patients
(younger than 18 years old) who presenting with focal skin lesions
and/or muscle involvement with slow flow on Doppler ultrasound were
considered to have VM by the expertise group of the Vascular Anomalies
Unit. All patients were included once parental representative had
provided signed informed consent.

Patients who had undergone recent treatment with possible haemostatic
modifiers, such as antiplatelets and anticoagulants, and those who had
experienced pain in the previous week were excluded from the study. All
procedures and actions were conducted in accordance with the World
Medical Association Declaration of Helsinki.

\emph{Collection data and preparation of samples}

The demographic and general characteristics of the patients and their
lesions were collected from clinical history.

Extralesional and intralesional venous blood samples were obtained from
patients in 3.8\% sodium citrate tubes (Vacutainer\textsuperscript{®},
BD, Becton Dickinson and Company, Madrid, Spain). Platelet-poor plasma
(PPP) was obtained by centrifuging the whole blood at 2500 g for 15 min
at 23ºC. Plasma samples were stored at -80ºC until analysis.

\emph{Conventional coagulation assays and rotational thromboelastometry}

Traditional coagulation analysis (haemogram, prothrombin time,
prothrombin activity, cephalin time, cephalin time ratio, INR and
D-dimer and fibrinogen values) as well as SDC-1 levels were performed in
whole blood or plasma, as appropriate.

Thromboelastometry, a global coagulation assay describing the dynamics
of clot formation and lysis, was performed using
ROTEM\textsuperscript{®} sigma with 500 \selectlanguage{greek}µ\selectlanguage{english}L of extralesional and
intralesional citrated venous blood in accordance with the
manufacturer's protocol. The samples were analysed using cartridges
containing the EXTEM/INTEM/FIBTEM/HEPTEM reagents. The minimum test
duration was 20 minutes, and the following parameters were recorded:
clotting time (CT), the time from test start until a clot firmness
amplitude of 2 millimetres is reached; clot formation time (CFT), the
time between 2 and 20 millimetres clot firmness amplitude is achieved;
clot amplitude at 5 and 10 minutes after CT (A5 and A10) and maximum
clot firmness (MCF).

A subsequent study was conducted on 9 paediatric patients and 11 healthy
controls with demographic and clinical characteristics similar to those
of the initial cohort. The aim of this study was to investigate
fibrinolytic clot properties. A modified EXTEM analysis was performed
with 360 \selectlanguage{greek}µ\selectlanguage{english}L of extralesional citrated venous blood and 125 ng/mL rtPA to
accelerate the fibrinolysis process ex vivo, according to the technique
described by Kuiper et al. . Values for lysis initiation time (LOT, the
time period from clotting time until 15 \% of clot lysis is achieved)
and lysis time (LT, time from CT until the clot firmness decreases to
10\% compared with MCF) parameters were recorded.

\emph{Glycocalyx analysis}

Levels of SDC-1 in plasma from extralesional and intralesional samples
were measured using a human CD138 ELISA kit (Diaclone, Besan\selectlanguage{ngerman}çon Cedex,
France)

\emph{Statistical analysis}

Quantitative variables were described using mean and standard deviation,
and the Wilcoxon paired test was used to compare these variables.
Correlation analyses between quantitative variables were carried out
using Pearson's ''R'' correlation coefficient, while the Mann-Whitney U
test was utilized for qualitative variables. In this study,
statistically significant differences were defined as those with a
probability of error of less than 5\% (p\textless{}0.05). Data analysis
was conducted using the SAS software version 9.4 (SAS Institute Inc.
Cari, NC).

Results (413)

Thirty paediatric patients with spongiform VM who underwent a
therapeutic procedure under sedation between February 2019 and March
2023 at the Vascular Anomalies Unit of the Hospital Universitario La Paz
were enrolled. The baseline patient characteristics are presented in
Table 1. The malformations corresponded to spongiform lesions
predominantly located in the upper extremities. Ninety percent of
patients experienced episodes of pain, although only 43.6\% required
pharmacological treatment during their evolution. Thirteen patients had
previously undergone sclerotherapy procedures, with an average of 3.4
procedures per patient. Ethoxysclerol was the most commonly used
sclerosing agent.

Table 2 lists the analytical parameters of the 30 patients. At the time
of analysis, the patients were free of clinically relevant
symptomatology and had not recently used drugs that could alter
coagulation parameters. Thirty patients (75\%) had fibrinogen levels
above 500 ng/mL, which is the cut-off point used in deep vein thrombosis
diagnostic and treatment algorithms , and only one patient had elevated
fibrinogen levels. All other parameters were within normal range.

Table 3 displays the results of the statistical comparisons between
extralesional and intralesional samples and the reference values. The
A10 and MCF values of the EXTEM test and MCF values of the INTEM test in
intralesional blood were found to differ from Oswald's reference values
, whereas those from extralesional blood where within the reference
range. The results of the EXTEM test showed significant differences
between the intralesional and extralesional blood samples in the clot
formation process (A5 and A10). When the cohort was analysed based on
the D-dimer cut-off point (500 ng/mL), patients with values \selectlanguage{english}\selectlanguage{english}lower than
the cut-off point (25\%) did not exhibit significant changes, whereas
patients with a D-dimer level \textgreater{} 500 ng/mL (75\%) showed
statistically significant differences in clot formation in both EXTEM
and INTEM between the intralesional and extralesional blood samples.
Table 4 and figure 1 show the results of the modified fibrinolysis phase
analysis.

SDC-1 exhibited significant variability in the different settings in
which it was measured. In the cohort of 15 patients, we observed a
substantial decrease in SDC-1 levels within the endothelial lumen (30.6
ng/mL) compared with the levels in extralesional samples (34.9 ng/mL)
and controls (35.6 ng/mL).

Possible correlations between D-dimer levels and parameters that have
traditionally been associated with the ILC phenomenon (sex, phleboliths,
location), together with significant analytical parameters of
ROTEM\textsuperscript{(r)} and SDC-1 levels, were analysed. No significant
correlation was detected, except for a strong correlation between the
intralesional and extralesional SDC-1 levels (correlation coefficient,
0.954).

Discussion (740)

Coagulation and fibrinolysis processes are intricate, and while some of
the proteins and enzymes involved can be measured, these values do not
accurately reflect the dynamic functionality of the systems at play.
Recent research has relied on biochemical models of HUVEC and analyses
of extralesional blood samples. Natynki et al. demonstrated that
mutations in TIE-2 produced alterations in the plasminogen-plasmin
system. However, studies on patients with extralesional blood samples
have been inconclusive .

Rotational thromboelastometry, or ROTEM\textsuperscript{(r)}, is an
instrument that enables the rapid and straightforward evaluation of
coagulation dynamics. Despite its prior utilisation , we used it in the
present study to analyse and compare intralesional blood samples from VM
with extralesional blood samples from the same patient. In our cohort,
we observed a loss of firmness of the intralesional clot, probably
caused by hyperfibrinolysis.

During the initial phase, we observed modifications in intralesional
blood values relative to the age-specific reference ranges of Oswald et
al. . Specifically, the A10 (46.7 and 48 s) and MFC (51.4 and 51 s)
parameters were below the normal range in both the EXTEM (extrinsic
pathway) and INTEM (intrinsic pathway). Although there were no reference
values for A5, they were significantly lower than those for the
extralesional samples. These findings suggest that the intralesional
clot does not reach its maximum potential relative to the reference
values and extralesional samples. Moreover, this effect is more
pronounced in patients with higher levels of D-dimer (\textgreater{} 500
ng/ml), significant alterations were observed in both INTEM and EXTEM.

The onset of coagulation, dependent on coagulation factors and
anticoagulants is reflected in the CT and CFT variables, was normal in
the analyses. The firmness phase, which is dependent on platelets and
fibrinogen and was assessed in the extralesional samples, also showed
normal values. Aronniemi et al, performed extralesional analyzes in a
cohort of patients who predominantly presented a venous endothelium, but
also lymphatic and capillary endothelium. According to our analysis,
they identified a decrease in the proteins responsible for stabilising
the clot in the final phase whereas 54.8\% had antithrombin levels above
their range . This anticoagulant molecule binds to heparan sulfate of
SDC-1, and alterations in the anchoring molecule can cause alterations
in the coagulation system .

VMs are characterised by a supposed hyperfibrinolytic component, as they
exhibit elevated D-dimer levels and the presence of phleboliths .
Viscoelastic studies allow the analysis of the fibrinolysis phase;
however, they require a long time and lose their clinical usefulness. To
address this issue, we have added recombinant tPA to accelerate
fibrinolytic process. Under these circumstances, we detected
hyperfibrinolysis in patients with VM. The alterations in the
coagulation system that occur in VM are partially reflected in the
intralesional samples because, as demonstrated in Figure 1, the
hyperfibrinolytic potential is not fully transferred to the
extralesional samples.

Endothelial dysfunction, resulting from modifications in the composition
of the glycocalyx, is a key factor in certain pathologies with a high
incidence and may act as a prothrombotic factor . In our study, we
identified a significant decrease in SDC-1 within the endothelial lumen
compared to extralesional samples.In the case of a quiescent and
unaltered endothelium, SDC-1 levels should be similar, but in line with
the hypothesis of Redondo et al., there is a persistent process of
seeking quiescence, which could disrupt angiogenic and haemostatic
regulatory systems .

ROTEM\textsuperscript{(r)} enables the identification of diverse
coagulation patterns in venous, lymphatic, and mixed endotheliums. In
addition, we will be able to perform early detection of susceptible
patients and the implementation of individualized prevention measures
based on their coagulation pattern. Furthermore,
ROTEM\textsuperscript{(r)} facilitates the monitoring of anticoagulant
treatments and evaluation of the effectiveness of therapies such as
sclerotherapy. SDC-1 is the first molecule to show a strong correlation
between intralesional and extralesional levels in VMs. This glycoprotein
has been proposed as a possible biomarker in different scenarios . In
our study, SDC-1 may serve as a novel endothelial biomarker, indicating
the stability of the ecosystem and enabling more precise monitoring of
treatment, as compared to D-dimer levels. This study has several
limitations: Since we did not perform a genetic analysis of the
malformations in which blood samples were obtained, we do not know the
venous endothelial behaviour under different mutational scenarios,
although most of the mutations identified in spongiform VMs are in the
TIE-2 gene . Lastly, the control group recruited was of adults, given
the difficulty in finding paediatric samples.

Conclusions (96)

The interaction between the endothelium and abnormal venous environment
plays a crucial role in determining the clinical and prognostic outcomes
of VM. Our findings suggest that endothelial dysfunction of genetic
origin can impair basic cellular systems, particularly the coagulation
system, which exhibits a notable reduction in clot quality due to
excessive fibrinolysis. Syndecan-1 has the potential to serve as a
sensor of endothelial well-being, given its strong correlation between
intralesional and extralesional levels, which may lead to the
identification of a range of values that pose no risk of clinical onset
or progression of the lesion.

\textbf{Conflict of Interest Disclosures (includes financial
disclosures):} The authors have no conflicts of interest to disclose.

\textbf{Funding/Support:} No funding was secured for this study.

\textbf{Role of Funder/Sponsor (if any):} None

\textbf{Clinical Trial Registration (if any):} None

\textbf{Acknowledgements:} None\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Characteristics} & \selectlanguage{ngerman}\textbf{Mean ± SD or\%(n)}\tabularnewline
\midrule
\endhead
Age, yo (±SD) & 11 \selectlanguage{ngerman}± 4.7\tabularnewline
Sex,\% (n) &\tabularnewline
Female & 53.3 (16)\tabularnewline
Men & 46.6 (14)\tabularnewline
Localization, \% (n) &\tabularnewline
Head and neck & 6.6 (2)\tabularnewline
Trunk & 3.3 (1)\tabularnewline
Extremity & 90 (27)\tabularnewline
Position, \% (n) &\tabularnewline
Upper & 43.3 (13)\tabularnewline
Lower & 56.6 (17)\tabularnewline
Phleboliths,\% (n) &\tabularnewline
Yes & 64.3 (18)\tabularnewline
No & 35.7 (10)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 1} . General characteristics\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Variables} & \selectlanguage{ngerman}\textbf{Mean ± SD} & \selectlanguage{ngerman}\textbf{Reference values
¹}\tabularnewline
\midrule
\endhead
Platelets (x10e3/\selectlanguage{greek}µ\selectlanguage{english}L) & 298 (576) & 180 - 490\tabularnewline
D-dimer (ng/mL) & 5041.5 (10939.6) & \textless{} 500\tabularnewline
Fibrinogen (mg/dL) & 241.4 (65.2) & 150 - 450\tabularnewline
Prothrombin time (s) & 11.5 (0.7) &\tabularnewline
Prothrombinactivity (\%) & 86 (12.3) & 70 - 120\tabularnewline
Partialthromboplastin time (s) & 28.2 (2.6) &\tabularnewline
INR & 1.1 (0.1) & 0.8 -- 1.2\tabularnewline
\textbf{Table 2}. Conventional analytical parameters \selectlanguage{ngerman}\emph{¹ Based on
the parameters of the center.} & \textbf{Table 2}. Conventional
analytical parameters \selectlanguage{ngerman}\emph{¹ Based on the parameters of the center.} &
\textbf{Table 2}. Conventional analytical parameters \selectlanguage{ngerman}\emph{¹ Based on
the parameters of the center.}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\textbf{Variables} & \textbf{Extralesional} & \textbf{Extralesional} &
\textbf{Intralesional} & \textbf{Intralesional} &
\emph{P}\textbf{-value} & \emph{P}\textbf{-value} & \textbf{References
values\textsuperscript{1}} & \textbf{References
values\textsuperscript{1}}\tabularnewline
\midrule
\endhead
\textbf{EXTEM} & & & & & & & &\tabularnewline
CT (s) & 64.4 (9.2) & 64.4 (9.2) & 78.5 (75.8) & 78.5 (75.8) & .811 & 44
- 91 & 44 - 91 & 44 - 91\tabularnewline
CFT (s) & 87.4 (10.2) & 87.4 (10.2) & 98.2 (14.7) & 98.2 (14.7) & .080 &
53 - 115 & 53 - 115 & 53 - 115\tabularnewline
A5 (mm) & 42.9 (6.4) & 42.9 (6.4) & 36.9 (11.9) & 36.9 (11.9) & .016* &
n/a & n/a & n/a\tabularnewline
A10 (mm) & 52.1 (5.6) & 52.1 (5.6) & 46.8 (11.8) & 46.8 (11.8) & .011* &
49 -67 & 49 -67 & 49 -67\tabularnewline
MCF (mm) & 55.9 (6.3) & 55.9 (6.3) & 51.6 (11.9) & 51.6 (11.9) & .103 &
53 -72 & 53 -72 & 53 -72\tabularnewline
\textbf{INTEM} & & & & & & & &\tabularnewline
CT (s) & 185.6 (26.3) & 185.6 (26.3) & 193.2 (103) & 193.2 (103) & .362
& 128 - 206 & 128 - 206 & 128 - 206\tabularnewline
CFT (s) & 83.3 (6.8) & 83.3 (6.8) & 89.7 (10.9) & 89.7 (10.9) & .109 &
45 - 106 & 45 - 106 & 45 - 106\tabularnewline
A5 (mm) & 43.4 (5.1) & 43.4 (5.1) & 40.4 (8.9) & 40.4 (8.9) & .161 & n/a
& n/a & n/a\tabularnewline
A10 (mm) & 51.4 (5.1) & 51.4 (5.1) & 48.3 (9.8) & 48.3 (9.8) & .323 & 48
- 67 & 48 - 67 & 48 - 67\tabularnewline
MCF (mm) & 54.4 (6.2) & 54.4 (6.2) & 51.2 (9.6) & 51.2 (9.6) & .174 & 54
- 71 & 54 - 71 & 54 - 71\tabularnewline
\textbf{FIBTEM} & & & & & & & &\tabularnewline
A5 (mm) & 10 (2.9) & 10 (2.9) & 6.5 (3.2) & 6.5 (3.2) & .290 & n/a & n/a
& n/a\tabularnewline
A10 (mm) & 11.1 (3.3) & 11.1 (3.3) & 10.5 (3.6) & 10.5 (3.6) & .432 & 7
- 22 & 7 - 22 & 7 - 22\tabularnewline
MCF (mm) & 11.7 (3.9) & 11.7 (3.9) & 11.1 (3.5) & 11.1 (3.5) & .356 & 8
- 24 & 8 - 24 & 8 - 24\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3} . Results from extralesional compared to intralesional

\emph{Note} . Values are presented as mean and (standard deviation).
*p-value of \textless{}0.05 was considered significant.

\textsuperscript{1}References values derived by Oswald et al.\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\textbf{Variables} & \textbf{Extralesional} & \textbf{Extralesional} &
\textbf{Controls} & \textbf{Controls} & \emph{P}\textbf{-value} &
\emph{P}\textbf{-value}\tabularnewline
\midrule
\endhead
\textbf{Modified EXTEM} & & & & & &\tabularnewline
LOT (s) & 1174 (362.3) & 1174 (362.3) & 1522 (286.6) & 1522 (286.6) &
.0158* & .0158*\tabularnewline
LT (s) & 2133 (490) & 2133 (490) & 2702 (767.4) & 2702 (767.4) & .036* &
.036*\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4} . Modified EXTEM analysis performed in presence of tPA.

\emph{Note} . Values are presented as mean and (standard deviation).
*p-value of \textless{}0.05 was considered significant.\selectlanguage{english}
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\textbf{Figure 1.} Modified EXTEM/tPA tracing in different environments

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\textbf{Hosted file}

\verb`Tables - Pediatric Blood &amp; Cancer.docx`  available at \url{https://authorea.com/users/700977/articles/687658-assessing-coagulopathy-and-endothelial-dysfunction-in-paediatric-venous-malformation-a-thromboelastometry-and-syndecan-1-study}

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