A 5-year old female presents with left hand pain. At birth, she had a bluish hue to the fingernail of her left thumb along with a compressible, blue colored mass (Fig 4). At 18 months of age she underwent an MRI which was consistent with a VM. After her diagnosis of VM, she was started on 3 mg/kg daily of aspirin given parenteral concerns of tenderness with palpation of the lesion. She is compliant with wearing a custom compression garment, but lately developed pain from her malformation despite aspirin therapy. Parents can occasionally palpate hardened nodules within the malformation, and also note a slight increase in the size of the VM. She has occasional short nosebleeds with dry weather, but no other bleeding symptoms. There is no significant family history of thrombosis or bleeding complications. She was initially examined by VIR, but referred to pediatric hematology given elevated d-dimer. Her most recent laboratory analysis revealed a platelet count of 275,000 (normal 150,000-450,000x109/L), d-dimer of 1200 ng/ml (normal <500 ng/ml), fibrinogen of 272 mg/ml (normal 213-435 mg/mL), partial prothrombin time of 28 seconds (normal 24 seconds - 32 seconds), and prothrombin time of 12 seconds (normal 11.5 seconds to 13.1 seconds).