Surgical management of arteriovenous malformation

doi:10.1016/j.bjps.2010.05.033

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 64, Issue 3, March 2011, Pages 283-291

https://doi.org/10.1016/j.bjps.2010.05.033 Get rights and content

Summary

This article presents our experience in managing a series of consecutive patients with arteriovenous malformation (AVM) referred to our Vascular Anomalies Centre over a 14-year period. These patients were culled from our prospective Vascular Anomalies Database 1996–2010. The medical records of these patients were reviewed to supplement the data collected.

Out of 1131 patients with vascular anomalies, 53 patients (22 males, 31 females) with AVM were identified. Their mean age was 29 (range: 3–88) years with 14 stage-III, 34 stage-II and five stage-I AVMs, affecting the head and neck area (n = 32), lower limb (n = 13), upper limb (n = 7) and trunk (n = 1). Eight patients with eight stage-III and 14 patients with 15 stage-II AVMs underwent definitive surgery following preoperative embolisation in 10 patients. Seventeen patients required reconstruction with free flaps (n = 8) or local or regional flaps (n = 9), tissue expansion (n = 4), tendon recession (n = 1), tendon transfer (n = 1), osseo-integration (n = 1) and skin grafting (n = 5). Fourteen patients required a combination of reconstructive techniques. During an average follow-up of 54 (range: 10–135) months, two (8.7%) lesions recurred but were improved following surgery. One patient with life-threatening stage-III AVM underwent ‘palliative’ surgery following preoperative embolisation and the lesion had improved and remained stable during the 4-year follow-up period.

AVM is a challenging clinical problem that requires a multidisciplinary team approach. Complete surgical excision remains the gold-standard treatment and immediate reconstruction is an integral part of definitive surgery for AVM. The heterogeneous nature of AVM requires treatment to be tailored for individual patients and the complex excision defects necessitate expertise in a variety of reconstructive techniques. Our experience shows a recurrence rate of 8.7% following definitive surgery for AVM.

Section snippets

Patients and methods

Consecutive patients with AVM referred to the Centre for the Study and Treatment of Vascular Birthmarks during 1996–2010 were culled from our prospective Vascular Anomalies Database comprising 1131 patients from within New Zealand and the South Pacific. All patients were assessed and followed up by our multidisciplinary team. The medical records of these patients with AVM were reviewed to supplement the data collected which included sex, age at presentation, anatomical location, symptoms,

Results

Fifty-three consecutive patients (22 males, 31 females) with the diagnosis of AVM were culled from the Vascular Anomalies Database. They represented 4.7% of the 1131 patients with vascular anomalies referred to our Vascular Anomalies Centre over a 14-year period. The mean age of presentation was 29 (range: 3–88) years. The primary location of the AVM was in the head and neck region (n = 32), lower limb (n = 13), upper limb (n = 7) and trunk (n = 1). Affected head and neck sub-sites included the ear (n =

Discussion

AVM is a relatively rare condition consisting of 4.6% of all patients referred to our Vascular Anomalies Centre. Our data confirm that AVMs present most commonly in the head and neck area followed by the upper and lower limb with a predilection for the periphery (i.e., hands and feet).² Solitary AVMs primarily involving the trunk are uncommon; AVM usually affects the soft tissues. Consistent with a previous report,² our study shows that the mandible, the facial bone, is the most commonly

Conflict of interest

None.

Funding

None.

Acknowledgement

We are grateful to Dr Hamish Lesley, Consultant Orthopaedic Surgeon at Hutt Hospital for his assistance with the management of one of our patients presented in this article.

References (14)

B.B. Lee et al.
Management of arteriovenous malformations: a multidisciplinary approach
J Vasc Surg
(2004)
J.Y. Kim et al.
Surgical treatment for congenital arteriovenous malformation: 10 years’ experience
Eur J Vasc Endovasc Surg
(2006)
Y. Jin et al.
Auricular arteriovenous malformations: potential success of superselective ethanol embolotherapy
Vasc Interv Radiol
(2009)
G.T. Richter et al.
Clinical course of arteriovenous malformations of the head and neck: A case series
Otolaryngology-Head and Neck Surgery
(2010)
Y. Yamamoto et al.
Experience with arteriovenous malformations treated with flap coverage
Plast Reconstr Surg
(1994)
M.P. Kohout et al.
Arteriovenous malformations of the head and neck: natural history and management
Plast Reconstr Surg
(1998)
J.P. Bradley et al.
Large arteriovenous malformations of the face: esthetic results with recurrence control
Plast Reconstr Surg
(1999)

There are more references available in the full text version of this article.

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The management of scalp AVMs can be challenging; therefore, focused, and accurate identification of the complexity of the vascular anatomy is required. The combined method of preoperative EE and SE showed satisfactory outcomes with low rates of complications and recurrence; thus, we recommend this approach for the management of scalp AVMs.
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Citation Excerpt :
AVMs are classified as congenital high-flow vascular anomalies and constitute only 4.7% of all vascular lesions. The central nervous system is the most common location for AVMs, whereas extracranial AVMs are rare [8,9]. AVMs are diagnosed according to history and clinical examination, combined with imaging characteristics.
Head and neck arteriovenous malformations are rare, congenital, and high-flow vascular malformations characterized by abnormal communication between feeding arteries and draining veins without intervening capillaries. Arteriovenous malformations are considered the most dangerous type of vascular malformation because progressive symptoms and infiltration can result in potentially life-threatening consequences. Left untreated, arteriovenous malformations can cause significant cosmetic deformities, severe bleeding, and high-output cardiac failure associated with arteriovenous shunting. The effective treatment of arteriovenous malformations located in the head and neck region is quite challenging due to high rates of recurrence and potentially lethal complications. We describe a case presenting with large arteriovenous malformations in the face and neck. Despite attempting several treatments, including external carotid artery ligation and embolization with liquid embolic agents, the patient continued to experience recurrence and symptoms of bleeding and pain. After admission, reconstructive plastic surgery was performed, supplemented by percutaneous direct puncture embolization, using glue injected into the venous and transarterial embolization. The patient was discharged with clinical recovery. Digital subtraction angiography remains the gold standard for assessing symptomatic and aggressive arteriovenous malformations, both before and after treatment. The treatment of head and neck arteriovenous malformations often requires a multidisciplinary approach to achieve the best clinical results.
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Cirsoid aneurysms, also known as arteriovenous malformations (AVMs), of the scalp are relatively rare lesions. They may be found incidentally or with symptoms such as an enlarging pulsatile mass, headache, or bleeding.
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^☆: This article was presented, in part, at the Royal Australasian College of Surgeons and Hong Kong College of Surgeons’ Conjoint Annual Scientific Congress, Hong Kong, People’s Republic of China, 11–16 May 2008 and at the 17th International Society for Study of Vascular Anomalies Workshop, Boston, USA, 21–24 June 2008.

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Surgical management of arteriovenous malformation☆

Summary

Section snippets

Patients and methods

Results

Discussion

Conflict of interest

Funding

Acknowledgement

J Vasc Surg

Eur J Vasc Endovasc Surg

Vasc Interv Radiol

Otolaryngology-Head and Neck Surgery

Experience with arteriovenous malformations treated with flap coverage

Plast Reconstr Surg

Arteriovenous malformations of the head and neck: natural history and management

Plast Reconstr Surg

Large arteriovenous malformations of the face: esthetic results with recurrence control

Plast Reconstr Surg