Surgical Treatment with or without Embolotherapy for Arteriovenous Malformations

Successful embolization of an anterior chest wall arteriovenous malformation using combined transfemoral and transradial approaches with onyx

We present a case of successful embolization of an anterior chest wall arteriovenous malformation (AVM) in a 24-year-old male patient. This report aims to highlight the efficacy and safety of using the liquid embolic agent (onyx) as well as the combined approaches (trans-femoral and trans-radial) in managing rare complex chest wall AVMs.

Hybrid surgery of arteriovenous malformation and aneurysm of the sole

The study describes the successful treatment of a rare type of arteriovenous malformation (AVM) in the sole using hybrid surgery, which consists of open resection and embolization. Moreover, the possibility of utilizing ultrasound during examination in addition to angiography for the diagnosing of AVM of the sole is proposed.

Embolo/sclerotherapy for the treatment of hand arteriovenous malformations: a single-center retrospective cohort experience

Purpose

To retrospectively report our preliminary experience of treating hand arteriovenous malformations (AVMs) with embolo/sclerotherapy.

Materials and methods

Retrospectively review the demographics, treatment detail, outcome data, and complications of 13 consecutive patients with hand AVMs from January 2018 to December 2021. We embolize the dominant outflow vein with elastic coils and then use absolute ethanol or polidocanol for intravascular sclerotherapy and bleomycin for interstitial sclerotherapy.

Results

Yakes type II presents in four lesions, type IIIa in six, and type IIIb in three. A total of 29 treatment episodes were conducted for the 13 patients (1 episode for 3 patients, 2 for 4 patients, and 3 for 6 patients; the repeated treatment rate was 76.9%). The mean stretched length of coils for 1 treatment episode was 95 cm. The mean absolute ethanol dosage was 6.8 ml (range 4-30 ml). In addition, 10 ml of 3% polidocanol foam was injected and interstitial sclerotherapy with 150,000 IU bleomycin was performed on every patient. The post-operative arterial-dominant outflow vein pressure index (AVI) increased in the 29 procedures (6.55 ± 1.68 vs. 9.38 ± 2.80, P < 0.05). The Mann-Whitney U test showed that the post-operative AVI was higher in patients without re-intervention (P < 0.05). Local swelling occurred after all the procedures. Blistering occurred in 6 of the patients in 13 (44.8%) of the 29 procedures. Superficial skin necrosis occurred in 3 of the patients in 5 (17.2%) of the 29 procedures. The swelling, blistering, and superficial skin necrosis recovered within 4 weeks. No finger amputation occurred. The follow-up time was 6 months. The 6-month assessment of clinical improvement after the last treatment episode showed that 2 patients were cured, 10 were improved, and 1 remained unchanged. With regard to angiographic evaluation, 9 showed partial response and 4 complete response.

Conclusion

Embolo/sclerotherapy can be effective and safe for hand AVM. The AVI increased significantly after embolo/sclerotherapy, and the index may be valuable in predicting recurrence in further study.

The addition of adjuvant radiotherapy in the management of extracranial arterio-venous malformations: a case discussion

Introduction:

The management of extracranial arterio-venous malformations (AVMs) is complex and often requires a multidisciplinary approach. Currently, treatment includes surgical resection and embolotherapy.

Methods:

We present the case of a foot AVM that was managed with adjuvant radiotherapy after previous surgery and embolotherapy had been attempted, and we discuss the role of radiotherapy in the management of extracranial AVMs.

Results:

The malformation was successfully eradicated with complete obliteration of the nidus and no recurrence.

Conclusions:

The addition of radiotherapy in the management of extracranial arterio-venous malformations offers promising results using similar doses to those used in brain AVMs.

Surgical management of auricular arteriovenous malformations: A literature review

Auricular arteriovenous malformations (AVMs) can cause a variety of symptoms that seriously impact the patient's appearance, life, and mental well‐being. Surgery is the primary management method for auricular AVMs, but there is no consensus on how to surgically manage auricular AVMs. In this article, we document a comprehensive review of the characteristics, classification, and surgical interventions to treat auricular AVMs.

Absolute Ethanol Embolization of Lip Arteriovenous Malformations: Observational Results from 10 Years of Experience

PURPOSE

To evaluate the safety and efficacy of ethanol embolization of lip arteriovenous malformations (AVMs).

MATERIALS AND METHODS

Seventy-six patients with lip AVMs were treated with 173 ethanol embolization procedures. Lip AVMs were treated with direct puncture alone in 21 patients (35 procedures, 20.2%), transarterial embolization alone in 13 patients (18 procedures, 10.4 %), and a combination of both in 60 patients (120 procedures, 69.3%). Adjunctive surgical resection was performed after embolization for cosmetic purposes based on the patient's request, including patient preference, functional impairment, and skin necrosis. The mean duration of follow-up was 30.9 months ± 27.6. The follow-up included clinic visits and telephonic questionnaires to evaluate the clinical signs and symptoms of AVMs as well as quality of life measures.

RESULTS

Of 76 patients, 51 showed 100% devascularization of AVMs, as determined using arteriography, followed by 23 with 76%-99% devascularization and 2 with 50%-75% devascularization. Of the 76 patients, 40 achieved complete symptom relief and 25 achieved major improvements in cosmetic deformity after embolization. Additionally, 54 patients achieved satisfactory function and aesthetic improvement with ethanol embolotherapy alone, whereas 22 achieved similar outcomes with a combination of ethanol embolotherapy and surgical intervention. Thirty-three adverse events (including 1 major) were documented.

CONCLUSIONS

Ethanol embolization of lip AVMs, as a mainstay, is efficacious in managing these lesions, with acceptable complications. Surgical resection after embolization may improve function and cosmesis in a subset of patients.

Surgical Management of Arteriovenous Malformation in the Foot: A Case Study

Arteriovenous malformations are frequently found in the head and neck, and are occasionally associated with congenital syndromes. They are rarely reported in the foot and ankle; however, when encountered in these particular locations, they may become painful and interfere with ambulation. Because of the lack of literature on pedal arteriovenous malformations, they remain enigmatic when encountered clinically. They form as a result of atypical development of the vascular system during embryogenesis. The identification, diagnosis, and treatment of an arteriovenous malformation can be challenging, because it may present similarly to more frequent soft-tissue pathologies in podiatric practice. These include fibroma, lipoma, ganglion cyst, or proteinaceous cyst. They have unpredictable behavior and a high recurrence rate. Failure to recognize and treat an arteriovenous malformation appropriately could result in ulceration, hemorrhage, and amputation. The identification and diagnosis must be accompanied with a full vascular work-up to determine the magnitude, flow, and extent of the lesion. After vascular work up, conservative, and surgical treatment options can be explored. This is an unusual case report of an arteriovenous malformation of the plantar foot that was previously misdiagnosed, and later presented to our facility for a second opinion. The steps taken for identification, diagnosis, and treatment are discussed along with surgical technique for excision of an arteriovenous malformation with successful outcome at 1 year follow-up. This case report will provide clinicians with armamentarium for diagnosis, workup, and treatment, when considering arteriovenous malformation in the differential diagnosis.

Vascular malformation and their unpredictable evolution: A true challenge for physicians

Vascular anomalies are mainly divided into two groups: vasoproliferative/vascular neoplasms (e.g., hemangioma), and vascular malformations (VMs). The main difference between the two resides in the histopathological assessment, while vascular tumors are true neoplasm, typically congenital with rapid postnatal growth, and eventual slow regression; VMs have a single endothelial cell lining, tend to be regarded as acquired despite being congenital in nature, can undergo sudden and massive growth, miming neoplastic proliferation. Arteriovenous malformation (AVMs) are one type of fast flow VMs, with a four-stage natural history, and potentially disruptive evolution. Magnetic resonance is the gold-standard for diagnosis and pre-operative planning while computer tomography is particularly valuable for AVMs involving bones, and selective angiography can define source / draining vessels for sclerotherapy and surgical planning. Given their unpredictable evolution, AVMs shouldn’t be treated until symptomatic, complicated, or aesthetically unacceptable. Surgical resection should be preceded by arterial embolization from 24 to 72 hours, which must be extensive in order to reduce the risk of recurrence. Pain due to ischemic condition is one of the most common and debilitating symptoms of AVM, while gassosus gangrene is the most feared complication as they can become pabulum for bacteria overgrowth eventually resulting in necrotizing fasciitis. Given their clinical evolution, VMs pose physicians at great challenge in identifying the best-suited treatment for each case. It is of paramount importance to be able to make accurate diagnosis, understand the basic physiology, and use appropriate diagnostic and treatment modalities to optimize outcome. Proper multidisciplinary approach along with constant psychological support is the basis for a successful final outcome. Aim of this work was to provide a deeper insight into these relatively uncommon pathology and related hardship that afflicts both patients and their families. (www.actabiomedica.it)

A Vascular Malformation in the Hand with Compromised Neurologic Status

BACKGROUND

Vascular malformations of the hand are rare vascular malformations that are challenging to treat.

METHODS

We present a case of a large vascular malformation with left hand pain and decreased sensation of the small and ring fingers. The lesion was treated operatively with surgical excision.

RESULTS

The malformation was successfully removed surgically, and pain resolved and numbness recovered by 2 weeks after surgery.

CONCLUSIONS

This is a rare case of large vascular malformation in the hand with compromised neurologic status. Surgical treatment provided complete relief of the disease, and the patient returned to normal daily activities.

Case Report of Ethanol and Cyanoacrylate Embolisation of a Recurrent Uncontrollable Torrentially Bleeding Arteriovenous Malformation of the Finger

Introduction

In general, arteriovenous malformations (AVMs) are extremely rare, with an incidence of only 1 in 100,000. They are rarer still in the hands and present variably with bleeding, heaviness, a pulsatile mass, pain, ulceration, or necrosis.

Report

The case of a 25 year old man with a rapidly bleeding right thumb AVM is presented. Bleeding was torrential and life threatening within a matter of seconds. He had previously undergone surgical ligation and embolisation twice at another centre, without success. At presentation, he had no thumb function and the bones of the thumb were exposed. An angio-embolisation was performed with ethanol and cyanoacrylate as the embolic agent. This was done using direct puncture into the AVM and also with a transarterial approach with microcatheters inserted into various unnamed branches feeding the AVM. Non-target embolisation and reflux was prevented by deploying a pneumatic tourniquet and mechanical elastic bands to confine the flow of the embolic agents within the AVM. Re-aspiration of the embolic agent post-embolisation was also performed to prevent local/systemic ethanol toxicity. Haemostasis was achieved without the need for further compression. A right thumb disarticulation was subsequently performed and the patient expressed great satisfaction with the outcome.

Discussion

AVMs in the hand are particularly challenging to treat owing to the need to preserve function of the myriad tissues and structural units that enable the many hand movements involved in activities of daily living. Even a partial loss of function may be disabling or poorly tolerated. The mainstays of treatment are embolisation, sclerotherapy, and surgical ligation/resection, all of which carry the potential for ischaemic injury to muscle and soft tissue. A holistic approach to management is desirable prior to selecting the appropriate management plan.

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Finger arteriovenous malformations (AVMs) are rare.

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Treatment of hand AVMs is associated with high complication rates and functional decline.

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Endovascular techniques can maintain function without permanent disability or recurrence.

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Ethanol ablation has shown permanence in AVM of the extremities.

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Use of glue and ethanol slows down the passage of ethanol, limiting collateral tissue damage.

Successful Complete Surgical Resection of a Large Venous Malformation of the Lower Extremity: A Case Report

Venous malformations (VMs) are the most common type of vascular malformations, resulting from errors in vascular morphogenesis. Because of the wide variety in their presentations, selecting the appropriate treatment, especially for large VMs, may be challenging. Herein, we report a case of a 59-year-old man with a large VM in the lower extremity who achieved favorable outcomes by complete surgical resection. Even large VMs can be successfully treated with surgery when patients are properly selected. An accurate and careful evaluation is essential for achieving optimal outcome in patients with VMs.

A nonsurgical approach to arteriovenous malformation of the foot a case report

There are few documented reports of arteriovenous malformations in the extremities, and even fewer specifically in the foot. Most of the documented cases in the foot present surgical treatments, and there is limited information on the nonsurgical approach. A brief review of the surgical approach to arteriovenous malformations in the foot and hand is presented first, followed by a case report of the nonsurgical treatment of an arteriovenous malformation in the foot, which was initially diagnosed incorrectly.