Congenital Vascular Malformations in the Hand and Forearm

Intraarterial polidocanol injection for the treatment of peripheral arteriovenous malformations

PURPOSE

The purpose of this study was to investigate the efficacy and safety of intraarterial transcatheter administration of polidocanol as an alternative treatment for peripheral arteriovenous malformations (AVMs).

METHODS

The study comprised 10 patients (six males and four females) with a mean age of 28.8 years (range 8-52 years). All patients had trunk or extremity AVMs. Following the administration of general anesthesia or intravenous (IV) sedation, the patients underwent staged intraarterial polidocanol sclerotherapy with or without additional embolizations for their AVMs. The administration of polidocanol was executed by intraarterial infusion through a microcatheter or by direct percutaneous entry into the nidus under ultrasound guidance.

RESULTS

A total of 19 sessions were accomplished in 10 patients. Polidocanol was used alone in six of the 19 sessions. In 13 sessions, polidocanol was used in combination with another agent (including n-butyl cyanoacrylate (NBCA), lipiodol, and ethanol) and/or coils. In two sessions, polidocanol was administered percutaneously under ultrasound guidance directly into the nidus documented by arteriography. No major complications occurred.

CONCLUSION

Intraarterial transcatheter administration of polidocanol alone or in combination with other agents is a safe and effective alternative treatment for peripheral AVMs.

[Imaging in diagnosis and treatment of vascular lesions of the hand]

Vascular lesions of the hand are challenging for diagnosis and treatment. These lesions are far more common than malignant tumors. Clinical presentation may be confusing and correct identification by imaging is sometimes mandatory. Standard X-rays and doppler ultrasound examination are the first modalities to be used. Doppler ultrasound help to characterize the lesion or/and to assess the flow velocity within the lesion. It allows to separate the high flow lesions (hemangioma, arteriovenous malformation) from the low or no flow lesions (venous malformation, cystic lymphangioma). MR imaging is the gold examination to define the size and the extension of the lesion to adjacent structures. Careful clinical and imaging evaluation and multidisciplinary staff decision are crucial before to propose embolotherapy and/or surgical treatment. In case of persistent doubt, a biopsy must be required. AVM must be excluded before to propose this biopsy sample. Interventional radiology can be used alone or in combination with surgery to treat vascular malformation (arteriovenous, lymphatic, venous, or mixed). Embolisation may either be done by percutaneous approach (all malformations) or by intravascular catheterization (arteriovenous malformation). Hemangioma is a benign tumor which most often spontaneously involutes with age. Vascular malformations of the hand are difficult to eradicate completely either with embolization or surgery or both. Recurrences are frequent. Management in multidisciplinary staff is mandatory and long follow-up is needed.

Imaging of the pediatric hand: Soft tissue abnormalities

This review attempts to demonstrate the spectrum of soft tissue masses encountered in the child's hand. The diagnosis may be suggested by the combination of physical exam and radiographs. Frequently the etiology of a soft tissue mass cannot be established by conventional radiographs and further imaging is necessary. MRI by virtue of its ability to provide detailed soft tissue characterization is the preferred method of imaging the problematic soft tissue mass.

Peripheral High-Flow Arteriovenous Vascular Malformations: A Single-Center Experience

PURPOSE

To assess the long-term outcomes of patients with high-flow arteriovenous malformations (HFAVMs) of the extremities.

MATERIALS AND METHODS

A retrospective review was performed to identify patients with HFAVMs referred for possible intervention between 1988 and 2003. Sixteen patients with upper-limb HFAVMs and 15 patients with lower-limb HFAVMs were identified (18 men, 13 women; mean age, 36.8 years; range, 21.1-72.2 years). Arteriography, duplex imaging studies, or magnetic resonance imaging were performed in all patients.

RESULTS

Follow-up was completed in 30 patients (mean duration, 3.3 years; range, 0.2-13 years), with one patient lost to follow-up. Nineteen had symptoms that warranted endovascular treatment: 13 underwent embolotherapy and six were considered unsuitable because of challenging anatomy that rendered embolization unsafe or impossible. Eleven patients' symptomatology did not warrant treatment and these patients were treated conservatively. The 13 patients treated with embolotherapy underwent a total of 27 treatment sessions (mean, 2.1 sessions per patient; range, 1-5). N-butyl cyanoacrylate and polyvinyl alcohol were used as the embolic agent in 11 and two patients, respectively. Three patients had complete resolution of HFAVM clinically and angiographically, and five patients' symptoms were controlled despite persistence of the HFAVM angiographically. Five patients had no improvement after treatment. Two major complications occurred (7.4% per session or 15.4% per patient): one patient developed a tibial plateau compression fracture and one patient had temporary L5 neuropathy after embolization of the pelvis and thigh. Of the six patients who were considered unsuitable for embolotherapy, one patient died of hepatocellular carcinoma, two had significant progression of symptoms, and the remaining three patients' symptomatology was unchanged. Only one of the nine patients with mild symptoms at presentation had symptom progression during follow-up.

CONCLUSIONS

Peripheral HFAVM is a rare and therapeutically challenging condition. Patients with minimal symptoms at presentation do well with conservative treatment, and symptomatic progression is infrequent. Only patients with significant symptomatology should undergo embolization therapy, which invariably requires multiple sessions and must be aimed at eradication of the nidus.