Outcomes of Live Virus Vaccination in Patients With Vascular Anomalies Being Treated With Sirolimus

BACKGROUND: Live vaccination in patients with vascular anomalies (VA) receiving sirolimus remains controversial due to immunosuppressive effects and theoretical risks. PROCEDURE: This single-center retrospective study included patients with VA less than 4 years old at the start of sirolimus therapy who were incompletely vaccinated. Immunologic evaluation during sirolimus therapy was categorized as normal, abnormal, or no/partial evaluation. Based on results, patients were encouraged to proceed with live attenuated vaccinations (varicella zoster virus [VZV]; measles-mumps-rubella [MMR]) or discussed with immunology. Vaccination outcomes were reviewed and reported descriptively. RESULTS: Among 45 eligible patients, 24 (53%) underwent complete immunologic evaluation. Thirteen of these (54%) had normal results; five of these (38%) were vaccinated while on sirolimus without complication. Eleven (46%) had abnormal evaluations; four of these (36%) were vaccinated while on sirolimus, with one developing a self-limiting varicella-like rash and fever. Twenty-one patients (47%) had partial or no immunological evaluation; 10 of these (48%) proceeded with vaccination while on sirolimus without complications. Overall, 24 patients (53%) received live vaccines (19 on sirolimus, five after holding sirolimus therapy for at least 2 months), with only one experiencing a mild vaccine-related event. No life-threatening complications occurred. CONCLUSION: In young patients with VA receiving sirolimus, live vaccine-associated infection risk appears low and comparable to rates in solid organ transplant recipients on immunosuppression. Immunologic evaluation may help identify those at higher risk, though most tolerated vaccination without adverse events. Our practice prioritizes varicella vaccination first, given the availability of effective treatment for potential complications.