Surgical treatment for congenital arteriovenous malformation: 10 years' experience

Surgical Management of Vascular Malformations of the Upper Extremity: A 12-Year Retrospective Cohort Study

INTRODUCTION

Vascular malformations (VMs) typically appear at birth and grow commensurately with patients. They can vary broadly in vessel type and tissue involvement, and upper extremity (UE) VMs can pose unique functional and aesthetic challenges in children. Given the advent of operative and nonoperative technologies like sclerotherapy and medications, a contemporary review of the surgical management of UE VMs is warranted.

METHODS

We performed a retrospective review of all patients who had surgical management of VMs from 2010 to 2021 at The Children's Hospital of Philadelphia. Demographics, lesion characteristics, treatment (including preceding nonsurgical therapies), complications, and final outcomes were recorded. Operative notes were reviewed for date of operation, depth of excision, type of closure, and current procedural terminology code.

RESULTS

Sixty-seven patients with 88 procedures were studied. Average patient age was 5.8 years, with 64% White and 67% male. Venous (34%) and lymphatic (19%) malformations were most common, and anatomic locations were most frequently on the hand (33%) and forearm (25%). The average lesion diameter was 4.2 cm, although this varied by location (eg, 2.9 cm, hand; 11.1 cm, chest wall). Fifty-eight patients (87%) underwent surgical excision as their index procedure, and 9 had sclerotherapy before surgery. Thirty-nine patients (60%) had subcutaneous excisions, and the remainder required subfascial or intramuscular excisions. Nearly all excisions were closed primarily (97%). Of the 53 patients with documented follow-up, 32 patients (60%) had complete resolution of their lesion as of their final visit. Thirty of these 32 patients with no clinical evidence of residual VM had only 1 surgery for excision.

CONCLUSION

Upper extremity VMs were composed of diverse conditions with varying vessel types, size, depth, and anatomic sites. Surgical excision of VMs of the UE was safe and effective. A majority of VMs were fully excised after 1 procedure and frequently closed primarily with relatively low complication rates. Future work should investigate decision-making and outcomes of all treatment options of VMs of the UE for optimal functionality and aesthetics.

The Efficiency and Safety of Ethanol Sclerotherapy for Labial Arteriovenous Malformations

BACKGROUND

AND PURPOSE: Labial arteriovenous malformations, usually with accompanying cosmetic defects, pain, and bleeding, are aggressive with characteristics of high risk of recurrence and absence of effective treatment. This study presents a technique of sclerotherapy for labial arteriovenous malformations.

METHODS

Patients with labial arteriovenous malformations were treated with percutaneous ethanol sclerotherapy with or without polyvinyl alcohol particle embolization. The efficiency, complications, and recurrence rate were analyzed with imaging and clinical follow-up data.

RESULTS

Of the 15 patients, all patients received one or more treatment sessions, from which eight realized a cure (53.3%) and five had remission (33.3%). Two patients who did not achieve an effective result await further treatment. Four (26.7%) patients treated with ethanol sclerotherapy combined with polyvinyl alcohol particle embolization developed recurrence. No recurrence occurred in patients treated with only sclerotherapy (mean ± SD follow-up 17.2 ± 8.1 months). Thirteen patients developed transient complications: swelling, mild bleeding, and blistering. One patient had a postoperative scar of about 0.5 cm.

CONCLUSIONS

Ethanol sclerotherapy appears effective as a treatment for labial arteriovenous malformations. Careful application of the treatment can reduce the occurrence of complications.

An integrated multidisciplinary team approach to the management of vascular anomalies: challenges and benefits

BACKGROUND

Vascular anomalies comprise highly variable pathophysiology and commonly pose diagnostic and management dilemmas. Consequently, patients often benefit from input from multiple specialists. This study describes the inception of a multidisciplinary team (MDT) Vascular Anomaly Clinic (VAC) in a tertiary paediatric centre, and the subsequent experience managing this complex patient group.

METHODS

This was a retrospective study of paediatric patients (< 18 years old) attending an MDT VAC from its inception in October 2012 until November 2019. Patient demographics, presentation, diagnosis and management were reviewed.

RESULTS

One hundred and thirty-three paediatric patients were seen over 7 years with a median age of 9.8 years. Vascular malformations were the most common diagnosis (88%), with venous malformations predominating (27%). The most common symptoms were pain (46%) and swelling (34%). Patients often required ≥ 2 investigations, with Doppler ultrasound (86%) and magnetic-resonance imaging (61%) being most common. Management included surgery (27%), sclerotherapy (26%), compression garments (23%), analgesia (12%), laser (15%), embolisation (5%) and sirolimus (3%).

CONCLUSIONS

The complex nature of vascular anomalies and high proportion of patients requiring multi-specialty management justified the establishment of an MDT VAC in our centre. Our experience demonstrates the success of an efficient one-stop MDT environment in the management of these challenging conditions.

LEVEL OF EVIDENCE

IV.

Clinical Course of Extracranial Arteriovenous Malformations

PURPOSE

Despite many advances in the knowledge of vascular malformations, extracranial arteriovenous malformations (AVMs) remain an enigma and are usually misdiagnosed and mismanaged due to their associated rare morbidity. This study aimed to describe the clinical course and emphasize the progressive nature of AVMs through a retrospective study of 446 patients.

METHODS

Patients with cutaneous and soft-tissue AVMs presenting to our Vascular Anomalies Center between March 2011 and March 2017 were reviewed. Medical records were examined for disease course, age at first presentation at our institution, distributions and locations of lesions, clinical staging, progression, and previous treatments. Progression was defined as advancement to a higher Schobinger stage from a lower stage.

RESULTS

A total of 446 patients (mean age, 25.6 ± 14.0 years) were enrolled in this study, including 232 (52.0%) males (gender ratio, 1.08:1). Arteriovenous malformations lesions in 76.7% (342/446) of the patients were located in the head and neck. Children with Stage I AVMs had a 41.9% risk of progression before adolescence and an 80.0% risk of progression before adulthood. Nearly all patients (96.2%) showed progression in adulthood. Diffuse lesions were more likely to progress than localized lesions (P < 0.05) in childhood and adolescence. Lesions in the head and neck regions were less likely to progress than those in other regions in childhood (P = 0.005). A total of 216 (48.4%) patients had undergone previous treatments. Among these patients, bleomycin showed an unintentional positive effect in the treatment of AVMs.

CONCLUSIONS

Extracranial AVMs have a continuously progressive nature. A full understanding regarding the progressive course of AVMs can lead patients and physicians to attach importance to early diagnosis and management. Meanwhile exploring innovative treatments should be focused in the future to prevent potential destructive progression.

An unusual arteriovenous malformation involving the cervical vessels treated with endovascular repair

We present an unusual and complex arteriovenous malformation involving the vertebral artery, subclavian artery, and internal jugular vein in a 31-year-old man with no history of trauma or catheterization. The repair was done using endovascular techniques to minimize complications from nerve or vascular injury. The massively dilated jugular vein has remained diminished in size and the patient has remained asymptomatic at 8 months. We discuss the occurrence of this rare malformation as well as treatment options along with their risks and benefits.

A Venous Malformation in the Vastus Lateralis: Our Experience with Cryotherapy

The present report describes a case of cryotherapy ablation in a 35-year-old woman with a 1.5 cm painful venous malformation (VM) in the right vastus lateralis muscle. After the patient had failed sclerotherapy, a single session of cryotherapy was performed that resulted in both technical and clinical success. At 8-month follow-up, there was no residual pain. The use of cryotherapy ablation for the treatment of an intramuscular VM has only been previously described on 1 occasion. Based on our results, cryotherapy is a promising therapy for fast and safe treatment for patients with venous vascular malformations.

Successful surgical resection of giant arteriovenous malformation in supraclavicular fossa

A 42-year-old woman with a large congenital giant arteriovenous malformation in the left supraclavicular fossa underwent surgical resection. Although endovascular treatment was initially planned, it was impossible to occlude the multiple feeding arteries (transverse cervical, clavicular branch of left internal mammary, thoracoacromial, anterior/posterior circumflex humeral), and the anatomy was difficult. After removal of the left clavicle, the arteriovenous malformation was exposed. Care was taken to not injure the brachial plexus, and each feeding artery was ligated, followed by division of the drainage veins. The postoperative course was uneventful, and no sign of recurrence has been seen.

Compartment Syndrome after Embolization of Arteriovenous Malformation

Management of arteriovenous malformations (AVMs) remains challenging because of their unpredictable course and high morbidity rate. In this case report, we present a patient with a huge AVM on the right calf who suffered complications of compartment syndrome, rhabdomyolysis, skin necrosis, and nerve damage after sclerotherapy. Limb salvage was achieved in spite of these devastating complications. A multidisciplinary team approach is important especially when making decisions for the management of a complicated AVM.

Morbidity and healthcare costs of vascular anomalies: a national study

PURPOSE

This study aimed to define morbidities and costs related to modern-day medical care for children with vascular anomalies.

METHODS

We reviewed the 2003-2009 Kids' Inpatient Database for pediatric patients (age < 21 years) hospitalized with hemangioma, arteriovenous malformation (AVM), or lymphatic malformation (LM). Patient characteristics, hospital complications, and hospital charges were compared by vascular anomaly type. Multivariable linear regression modeling was used to determine predictors of increasing hospital costs for patients with AVMs.

RESULTS

In total, 7485 pediatric inpatients with vascular anomalies were identified. Frequently associated complications included chronic anemia (4.0%), sepsis (4.6%), and hypertension (2.4%). Children with AVM had the highest rate of in-hospital mortality, compared to those with hemangiomas or LM (1.0% vs. 0.1% vs. 0.3%, p < 0.001). AVMs were also associated with the highest median hospital charge, more than twice the cost for hemangiomas or LM ($45,875 vs. $18,909 vs. $18,919; p < 0.001).

CONCLUSIONS

There is a significant rate of morbidity in children with vascular anomalies, most often from blood loss and infection. The greater cost of AVM care may be related to the higher mortality rate, associated complications, and complexity of procedures required treating them. Cost-effective management of vascular anomalies should target prevention and the early recognition of both chronic comorbidities and acute complications.

Surgical and Endovascular Management of Arteriovenous Malformation: Case Series from a Single Center

Management of arteriovenous malformation (AVM) remains a major challenge to vascular surgeons. A multidisciplinary approach was introduced in our hospital to manage these cases from October 2003 to date. This is a report of our experience in their management. A prospective study was done on all patients with symptomatic AVM admitted to our unit between October 2003 and May 2006. All patients had preoperative duplex scanning and magnetic resonance imaging with or without conventional angiography. A multidisciplinary team assessed and treated these cases according to the type of malformation. Thirty-two cases were included in this study, with a mean follow-up of 18.3 months. Of these, 20 cases were predominantly venous and treated with surgical excision ( n = 14) or ethanol sclerotherapy ( n = 6). Twelve cases were predominantly arterial or arteriovenous shunting; 10 were treated with preoperative embolization followed by surgical excision and the remaining 2 with superselective embolization alone. The overall complication rate was high (31%). However, all were minor and settled down conservatively. No recurrence was observed in the early follow-up period. Management of AVM by a surgical and endovascular approach can deliver excellent results, with acceptable morbidity and no recurrence in the early follow-up period.

Sclerotherapy using 1% sodium tetradecyl sulfate to treat a vascular malformation: a report of two cases

Vascular malformations are the most common congenital and neonatal vascular anomalies in the head and neck region. The demand for simple and esthetic vascular malformation treatments have increased more recently. In this study, two patients that were diagnosed with venous malformations were treated with sodium tetradecyl sulfate as a sclerosing agent. Recurrence was not found one year after the surgery. This article gives a brief case report of sclerotherapy as an effective approach to treat vascular malformations in the oral cavity.

Giant Arteriovenous Malformation of the Neck

Arteriovenous malformations (AVM) have a wide range of clinical presentations. Operative bleeding is one of the most hazardous complications in the surgical management of high-flow vascular malformations. In the cervical region, the presence of vital vascular structures, such as the carotid artery and jugular vein, may increase this risk. This is a case of massive arteriovenous malformation deforming the neck and the face aspect of this aged lady and growing for several years. A giant mass of the left neck occupied the carotid region and the subclavian region. The AVM was developed between the carotid arteries, jugular veins, and vertebral and subclavian vessels, with arterial and venous flux. The patient underwent surgery twice for the cure of that AVM. The first step was the ligation of the external carotid. Seven days later, the excision of the mass was done. In postoperative period the patient presented a peripheral facial paralysis which completely decreased within 10 days. The first ligation of the external carotid reduces significantly the blood flow into the AVM. It permitted secondarily the complete ablation of the AVM without major bleeding even though multiple ligations were done.

Early symptoms and long-term clinical outcomes of distal limb's cutaneous arterio-venous malformations: a retrospective multicentre study of 19 adult patients

INTRODUCTION

Cutaneous arterio-venous malformations (AVM) are high-flow vascular malformations made up of a direct link between arteries and veins without intermediary capillary space. 'Distal limb's AVM', which mean involving hands or feet, are rare and their functional prognosis is often poor. Little is known about their early clinical symptoms. The objectives of this study were to identify early clinical symptoms of distal limb's cutaneous AVMs and to determine their long-term clinical outcome.

METHODS

A retrospective study was carried out including adult patients who had distal limb's AVM, who were followed up between January 2000 and November 2013 in two regional tertiary care centres. The information was collected from patients' clinical records and completed by a structured telephone questionnaire.

RESULTS

Nineteen patients were included in the study: four (21%) with foot AVM and 15 (79%) with hand AVM. The first clinical symptoms were as follows: swelling (47%), pain (47%), one or several venous dilatations (37%) and rarely abnormal skin colour, hyperthermia and pulsating sensation. The median diagnosis delay was 9 years after the onset of first manifestations. Amongst the 17 patients who underwent a treatment, 53% had embolotherapy session(s), 12% surgery and 35% had both. After an average follow-up of 57.6 months, 31% of the 13 patients contacted who were receiving treatment were in complete remission; 31% had partial remission; 15% had relapse after initial improvement and 23% had treatment failure. Overall, 74% of patients had a serious development of the AVM: 37% had digital or hand amputation, and 42% remained symptomatic and/or unstable.

CONCLUSION

This study suggests that initial manifestations of distal limb's AVMs are discreet and non-specific, leading to a diagnosis delay of about 10 years, with poor prognosis. Doctors should evoke the diagnosis earlier, when these symptoms are shown: pain and/or swelling, sometimes with a large vein.

Comprehensive treatment and rehabilitation of a patient with maxillary arteriovenous malformation

Arteriovenous malformations (AVMs) of the maxilla are rare and potentially life-threatening conditions that can pose a therapeutic dilemma. We reported the first case of maxillary AVM in a 15-year-old girl who was treated by marginal hemimaxillectomy including overlying palatal mucosa and immediate replantation of the segment after removing the AVM tissues and teeth and covering by a full-thickness pedicled temporal muscle flap rotated into the mouth. Then, this preserved bone underwent distraction osteogenesis and dental implant rehabilitation successfully. This method was previously used for the definitive treatment of mandibular AVMs, and in this case, we applied this method for the first time in maxillary AVMs. In conclusion, this surgical method may be considered as a safe, convenient, and effective treatment and reconstructive modality for such vascular malformations in the maxilla and restores function and symmetry of the jaws while obviating the need for bone harvesting and future major reconstructive operations.

A xenograft animal model of human arteriovenous malformations

Background

Arteriovenous malformations (AVMs) are a type of high-flow vascular malformations that most commonly occurs in the head and neck. They are present at birth but are usually clinically asymptomatic until later in life. The pathogenesis of AVMs remains unclear and therapeutic approaches to AVMs are unsatisfied. In order to provide a tool for studying the pathogenesis and therapies of this disease, we established and studied a xenograft animal model of human AVMs.

Methods

Fresh human AVMs specimens harvested from 4 patients were sectioned (5x5x5 mm) and xenografted subcutaneously in 5 immunologically naïve nude mice (Athymic Nude-Foxn1^nu). Each mouse had four pieces specimens in four quadrants along the back. The grafts were observed weekly for volume, color and texture. The grafts were harvested at every 30 days intervals for histologic examination. All grafts (n = 20) were sectioned and stained for hematoxylin and eosin (H&E). Comparative pathologic evaluation of the grafts and native AVMs were performed by two blinded pathologists. Immunohistochemical examination of human-specific nuclear antigen, vascular endothelial growth factor receptor-2 (VEGFR-2) and Ki-67 was performed.

Results

Clinical characteristics and pathologic diagnosis of native human derived AVMs were confirmed. 85% (n = 17) of AVM xenografts survived although the sizes decreased after implantation. Histological examination demonstrated numerous small and medium-size vessels and revealed structural characteristics matching the native AVMs tissue.76.5% (n = 13) of the surviving xenografts were positive for Ki-67 and human-specific nuclear antigen suggesting survival of the human derived tissue, 52.9% (n = 9) were positive for VEGFR-2.

Conclusions

This preliminary xenograft animal model suggests that AVMs can survive in the nude mouse. The presence of human-specific nuclear antigen, VEGFR-2, and Ki-67 demonstrates the stability of native tissue qualities within the xenografts.

Oral capillary hemangioma: a clinical protocol of diagnosis and treatment in adults

PURPOSE

Hemangiomas are benign vascular anomalies characterized by benign proliferation of blood vessels. There are no well-defined criteria for the diagnosis and treatment of oral capillary hemangioma (OCH). The objective of this study is to report a safe, effective, and low-cost protocol for diagnosis and treatment of OCH.

MATERIALS AND METHODS

Eight patients were diagnosed with OCH, through two physical examination maneuvers-the diascopy and head lowering maneuver with abdominal compression (HLMAC). The treatment performed was sclerotherapy with ethanolamine oleate, weekly, until the disappearance of the lesion. No local anesthetics were administered prior to the sclerosing agent injection.

RESULTS

All cases showed a complete remission of the lesions after sclerotherapy. There were no visible scars or compromise esthetics or normal function, and there was no evidence of recurrence. Only one patient had superficial ulceration, which remained asymptomatic and healed without specific treatment.

CONCLUSIONS

This protocol was effective in the diagnosis of OCH through two physical examination maneuvers with low-cost and easy implementation, the diascopy and the HLMAC. The low concentration associated with a reduced amount of the sclerosing agent was responsible for the excellent results in the cases treated.

Is a swine model of arteriovenous malformation suitable for human extracranial arteriovenous malformation? A preliminary study

OBJECTIVE

A chronic arteriovenous malformation (AVM) model using the swine retia mirabilia (RMB) was developed and compared with the human extracranial AVM (EAVM) both in hemodynamics and pathology, to see if this brain AVM model can be used as an EAVM model.

METHODS

We created an arteriovenous fistula between the common carotid artery and the external jugular vein in eight animals by using end-to-end anastomosis. All animals were sacrificed 1 month after surgery, and the bilateral retia were obtained at autopsy and performed hematoxylin and eosin staining and immunohistochemistry. Pre- and postsurgical hemodynamic evaluations also were conducted. Then, the blood flow and histological changes of the animal model were compared with human EAVM.

RESULTS

The angiography after operation showed that the blood flow, like human EAVM, flowed from the feeding artery, via the nidus, drained to the draining vein. Microscopic examination showed dilated lumina and disrupted internal elastic lamina in both RMB of model and nidus of human EAVM, but the thickness of vessel wall had significant difference. Immunohistochemical reactivity for smooth muscle actin, angiopoietin 1, and angiopoietin 2 were similar in chronic model nidus microvessels and human EAVM, whereas vascular endothelial growth factor was significant difference between human EAVM and RMB of model.

CONCLUSIONS

The AVM model described here is similar to human EAVM in hemodynamics and immunohistochemical features, but there are still some differences in anatomy and pathogenetic mechanism. Further study is needed to evaluate the applicability and efficacy of this model.

Radiologically guided percutaneous cryotherapy for soft tissue tumours: A promising treatment

Studies of percutaneous cryotherapy in the treatment of benign or malignant soft tissue tumours are rare and mainly involve small populations. Nevertheless, results show cryotherapy's potential in terms of local control of tumours, analgesic efficacy, reduced intra- and postoperative complications, and reduction in the length of convalescence after the procedure. The objective of this update is to set out the short-term prospects for this technique in the treatment of soft tissue tumours, so that it may be more widely offered in these indications.

Surgical Treatment with or without Embolotherapy for Arteriovenous Malformations

OBJECTIVE

The management of arteriovenous malformations (AVMs) remains challenging due to the high rate of recurrence of these lesions. Surgical resection is the only potential cure; however, it is often difficult to perform and carries a risk of massive hemorrhage. The purpose of this study was to review our experience with AVMs treated by surgical resection.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of nine patients with AVM, treated with surgical resection. We treated these patients with excision surgery with or without embolotherapy.

RESULTS

Eight were treated with surgical resection with embolotherapy and one was treated with a simple surgical resection. Five patients with AVMs were cured. However, two cases of AVM recurred after total excision, and AVMs remained in two cases of partial excisional surgery in which the lesions involved the joints.

CONCLUSIONS

Total excision of AVMs leads to a cure; however, total excision is not adequate in cases of AVMs involving the joints. Multidisciplinary treatment may offer good results in reducing the morbidity. To minimize complications related to surgery, aggressive control of blood flow to the lesion, preoperatively, with appropriate embolotherapy is essential, and a complete resection with a chance of cure will be increased.

Percutaneous cryotherapy of vascular malformation: initial experience

The present report describes a case of percutaneous cryotherapy in a 36-year-old woman with a large and painful pectoral venous malformation. Cryoablation was performed in a single session for this 9-cm mass with 24 h hospitalisation. At 2- and 6-month follow-up, the pain had completely disappeared, and magnetic resonance imaging demonstrated a significant decrease in size. Percutaneous cryoablation shows promise as a feasible and apparently safe method for local control in patients with symptomatic venous vascular malformations.

Facing the World: audit of activity 2002-2010

BACKGROUND

Craniofacial anomalies, although uncommon, can have considerable effects on the individual, their family and society.(1-4) They carry with them a large morbidity and require a highly specialized, multidisciplinary approach to treatment.(5) Facing the World (FTW), was founded in 2002, to offer facial reconstructive surgery to children with complex, craniofacial anomalies with no prospect of local treatment, from developing countries anywhere in the world.

METHODS

We present an 8-year audit of the cases treated by FTW, where children are brought from their own countries to the UK for treatment. Patient selection takes place prior to their arrival in the UK by a multidisciplinary team. Specifically the condition has to be correctable to a degree that justifies the risks involved with the surgery, and the disruption to the child and their family.

RESULTS

Since inception, FTW has evaluated more than 300 cases and provided treatment in the UK for over 24 cases from 18 different countries. We present our range of cases and complications. We discuss our complication rate of 28% and mortality rate of 4% (1 case).

CONCLUSIONS

Key to the sustainability of FTW is the development of local healthcare infrastructure within the developing countries to facilitate eventual local management of the more straightforward cases and follow up of these patients by well-trained medical staff. By establishing these programs, FTW aims to not only change these children's lives but to raise awareness, and help to expand the global craniofacial network whereby in the future, satellite partners will be present to help manage these conditions locally.

LEVEL OF EVIDENCE

III.

Alcohol sclerotherapy to treat vascular malformations in the oral cavity

OBJECTIVE

To present our experience in treating vascular malformations in the oral cavity solely by injecting ethanol into the lesions.

MATERIAL AND METHODS

We treated 26 patients (12 men and 14 women) with oral malformations. The diagnosis was based on clinical findings (n=26), magnetic resonance imaging studies (n=19), angiography findings (n=5), and direct puncture venography (n=2). To achieve sclerosis, we administered absolute ethanol through direct puncture. All interventions were performed under deep sedation.

RESULTS

The vascular malformations treated ranged from 7mm to 60mm (median: 24.5mm) in maximum diameter and had been present in the oral cavity for 0.2 to 54 years (mean: 13.6 years). The median age of the patients was 44.5 years (range: 12-87 years). The reason for treatment of the malformation was: an increase in size (n=8), local bleeding (n=11), risk of bleeding during dental extraction (n=5), pain (n=1), and esthetic purposes (n=3). Lesions were located in the mucosa of the cheek (n=12), in the facial gingiva (n=5), in the labial mucosa (n=6), in the tongue (n=3), in the pterygomandibular region (n=1), and in the palate (n=1). The median dose of ethanol was 3.2mL. Twenty lesions disappeared after a single injection session, five after two sessions, two after three sessions, and one after five sessions. In 20 cases all signs of the lesions disappeared, in 6 a bluish macule persisted, and in 2 a mass effect persisted. The symptoms improved in all patients. Only transient complications of sclerotherapy were observed: local inflammation, perioral paresthesia in two patients, and necrosis of the mucosa of the cheek in one.

CONCLUSIONS

Alcohol sclerotherapy is an efficacious procedure for treating vascular malformations in the oral cavity.

Novel image-guided management of a uterine arteriovenous malformation

The investigators present a novel image-guided embolization, not previously described, of a uterine arteriovenous malformation (AVM) resistant to endovascular management. The uterus was exposed surgically, and Histoacryl (Braun, Fulda, Germany) was injected directly into the nidus using ultrasound guidance and fluoroscopy. The patient had a successful full-term pregnancy after this procedure. This technique may be a useful alternative management strategy in patients with uterine AVM who fail traditional endovascular embolization and who still desire fertility.

Clinical course of arteriovenous malformations of the head and neck: A case series

Objective: To demonstrate, in a case series, the relentless growth of arteriovenous malformations (AVMs) of the head and neck and the importance of their vigilant management within the context of a modified staging system.

Study Design: Retrospective review.

Setting: Tertiary care institution, Vascular Anomalies Center.

Subjects and Methods: Subjects were patients with advanced AVMs presenting to our Vascular Anomalies Center. Medical records were examined for age at first diagnosis, disease course, prior treatments, age at presentation, management, therapeutic outcomes, stage of disease, and impact on quality of life. Early patient photographs were evaluated.

Results: Ten patients (ages 13-46 yrs) with extensive cervicofacial AVMs were examined. Progressive growth, worsening symptoms, and graduated disease stage were universally experienced by each patient, as evident by serial photographs, over a course of many years. Each patient presented to our institution with massive lesions, bleeding, pain, and facial destruction. Prior embolization and/or surgery had been performed in all but one patient. Every patient had been previously told that their AVMs were incurable or that treatment options were exhausted. The patients were subsequently treated at our institution with surgical resection with or without preoperative embolization. Disease control, symptom improvement, and enhanced daily functioning were attained in each patient.

Conclusion: The natural course of AVMs is progressive, invasive, and destructive. Vigilant observation, early treatment, and radical therapy are necessary for AVMs of the head and neck.

Arterio-venous malformation: how much do we know?

Arterio-venous malformation (AVM) is a congenital vascular malformation that is neither a venous malformation nor a haemangioma. An AVM is a potentially life-threatening and limb-threatening lesion, especially the 'fistulous' truncular form due to its unique embryological and haemodynamic characteristics. AVM treatment requires an early aggressive approach, one that is careful and based on a thorough assessment of the risks and benefits associated with the treatment plan. A successful treatment strategy requires an accurate assessment of the AVM taking into account the extent, severity and progression of the lesion. This is critical in order to minimize the morbidity associated with the currently available therapies. A multidisiciplinary approach that integrates endovascular and surgical therapy can substantially improve the treatment results seen in patients with AVMs. Preliminary treatment of a fistulous AVM with coil embolization is essential in order to minimize associated morbidity and to alter the lesion haemodynamics from a high-flow lesion to a low-flow lesion that is more amenable to subsequent, definitive management with ethanol or NBCA glue embolo/sclerotherapy.

Endovascular management of an arteriovenous malformation using an occluder stent graft

A 58-year-old woman presented with gangrene of the left upper arm stump caused by an arteriovenous malformation originating from the subclavian artery. She had been treated unsuccessfully in the past with repeated attempts of coil embolization and débridement, but finally she underwent arm amputation. A 14 mm diameter occlusion self-expandable stent was placed in the left subclavian artery via ipsilateral brachial artery access, with immediate and complete interruption of arterial supply to the vascular malformation. This minimally invasive treatment provides an alternative method of management of arteriovenous malformations in the subclavian region.

Clinical features and characteristics of blood flow of uterine vascular abnormalities

PURPOSE

The purpose of this study was to assess the clinical features and characteristics of the blood flow in uterine vascular abnormalities using ultrasound and magnetic resonance imaging (MRI).

METHODS

A total of 17 women were diagnosed with uterine vascular abnormalities by ultrasound. The clinical characteristics of the patients and the distribution and waveform of the intrauterine vessels were examined using transvaginal gray-scale and Doppler ultrasonography, spin-echo MRI, and MR angiography.

RESULTS

The average age of the 17 subjects was 44.3 years, and 5 were postmenopausal women. The number of pregnancies and deliveries was 2.0 and 1.7, respectively. Of the 17 subjects, 7 had a moderate or severe grade of dysmenorrhea and 7 had a history of vascular disease. In all subjects, vaginal ultrasound demonstrated tubular or numerous tortuous anechoic areas in the uterine wall, and Doppler ultrasound showed that the tubular or numerous dilated tortuous vessels had an atypical wave flow, unlike that of an artery or a vein. The distribution of displayed flow varied, and the waveforms of the Doppler ultrasound displayed three patterns. The averages of the pulse Doppler flow indices showed low impedance in the abnormal uterine vessel and the uterine artery, especially in cases of true arteriovenous malformations. MR angiography demonstrated distinct, tortuous, and coiled vascular channels in the pelvis during and just after the arterial phase.

CONCLUSION

Characterization of the clinical features of uterine vascular abnormalities is considered to be valuable for obstetricians and gynecologists.

Incidence of soft tissue injury and neuropathy after embolo/sclerotherapy for congenital vascular malformation

PURPOSE

Embolo/sclerotherapy is an important treatment modality for vascular malformations, but the rates and results of the complications associated with embolo/sclerotherapy are not well known. We report the incidence and outcome of soft tissue injury and neuropathy after performing embolo/sclerotherapy for congenital vascular malformations (CVMs) classified according to the Hamburg classification.

METHODS

Among 1823 patients with CVM, 573 were treated with embolo/sclerotherapy. We retrospectively reviewed 68 patients (31 males, 37 females; mean age, 20.0 years) with soft tissue injury and 49 patients (16 males, 33 females; mean age, 21.2 years) with neuropathy. The indications for embolo/sclerotherapy for CVM were that the CVMs affected the quality of life, such as a symptomatic or trauma-prone lesion or a lesion that was impairing the function of a limb, and the lesions that were located near a life-threatening vital area, including the airway. As embolo/sclerotherapy agents, absolute or 80% ethanol, N-butyl cyanoacrylate (NBCA), and various types of coils or contour particles were used in various combinations, either at the same time or in phases, depending on the location, severity, and extent of the CVM.

RESULTS

The incidence of soft tissue injury was 29.4% (42 of 143) for the arteriovenous shunting type and 8% (22 of 273) for the venous type. No soft tissue injuries occurred in the patients with arterial and lymphatic malformations. Of the 68 patients with soft tissue injury, 40 lesions healed with conservative management, and 28 lesions needed surgery, including escharectomy, skin graft, or amputation. The incidence of neuropathy was 10.9% (30 of 273) for the venous CVM. No neuropathy occurred in the patients with arterial malformations. Of the 49 patients with neuropathy, 42 recovered at a mean period of 5.3 months, but seven did not.

CONCLUSION

Soft tissue injuries occurred in 11.9% of patients (68 of 573) and neuropathies occurred in 8.6% (49 of 573) after undergoing embolo/sclerotherapy. Most of these complications recovered by themselves (58.9% from soft tissue injury and 85.1% from neuropathy). Our results suggest that embolo/sclerotherapy has an acceptable incidence of soft tissue injury and neuropathy, when considering the effect that the CVM had on the quality of life before treatment, so embolo/sclerotherapy is recommended as a treatment modality for CVM.