Tumescent solution: a game changer in excising refractory arteriovenous malformation.

Arteriovenous malformations of the head and neck are rare and inborn errors of vascular morphogenesis. They pose therapeutic challenges owing to their bleeding tendency and a high chance of recurrence. Treatment modalities include digital subtraction angiography with embolisation as a primary treatment or can be done preoperatively followed by surgical excision. We present a case of recurrent arteriovenous malformation of the postauricular region in an adolescent male who was taken up for upfront surgical excision with the help of a tumescent solution, thereby eliminating the need for embolisation and drastically reduced intraoperative blood loss.

Microsurgical Treatment for Arteriovenous Malformations in the Hand.

Vascular malformations in the extremities are a common site of occurrence; arteriovenous malformations (AVMs) are the least frequent of all vascular malformations, estimated at 5% to 20%. The first step in management is to perform a thorough clinical examination. Symptoms are assessed, and staging is performed using the Schobinger classification. Next, ultrasonography and contrast-enhanced computed tomography are used to confirm the diagnosis of AVM and to confirm the extent of the malformation. Surgery is the first-line treatment and reconstruction is performed. In cases where surgery is not feasible, embolization and sclerotherapy may be used to alleviate symptoms.

Surgical Treatment of Spontaneous Superficial Temporal Artery Arteriovenous Malformation: A Case Report.

BACKGROUND An arteriovenous malformation (AVM) is an abnormal connection between an artery and a vein, bypassing the capillary network. An AVM of the superficial temporal artery (STA) can occur after trauma, iatrogenic injury, infection, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few reported cases. Symptoms include local pain, headache, tinnitus, or paresthesia, in addition to a palpable mass associated with thrill on palpation. Options for diagnosis include intra-arterial angiography, doppler ultrasound, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Current management options include surgical excision, ligation, and embolization; however, it is unknown which treatment is superior in terms of recurrence and which carries a lower risk of complications. CASE REPORT We present a case of a spontaneous STA AVM in a 76-year-old woman with past medical history significant for seasonal allergies and hyperlipidemia, who presented with pulsatile tinnitus and a palpable, tender mass located to the left temporal area. The mass had been present for several years, with gradual increase in size two to three years prior to presentation. She denied any history of trauma or procedure prior to presentation of the pulsatile mass. She underwent open excision with complete resolution of symptoms and no recurrence at 11-month follow-up. CONCLUSIONS AVM of the STA is a condition that can occur secondary to trauma, infection, iatrogenic injury, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few cases documented in the literature. Surgical treatment remains the standard of management, with options including surgical excision, ligation, or embolization.

Combined Preoperative Endovascular Embolization and Surgical Excision for Scalp Arteriovenous Malformations: A Systematic Review and Case Illustration.

OBJECTIVE: To evaluate the efficacy of the combined approach of preoperative endovascular embolization (EE) and surgical excision (SE) for scalp arteriovenous malformation (AVM) and present an illustrative case report. METHODS: A systematic review was conducted using online databases (PubMed/Medline, Cochrane, and Embase) on February 15, 2023. The inclusion criteria were any type of study of patients with scalp AVMs who were diagnosed and confirmed through angiography and treated with combined preoperative EE and SE. All the articles that met the inclusion criteria were included in this study. RESULTS: A total of 49 articles (91 patients) were included. The patients' age ranged from 10 days to 70 years at the time of presentation. The most common symptoms were a pulsatile mass in 51 patients (56.04%), progressively growing mass in 31 patients (34.06%), and bruits and/or thrills in 22 patients (24.17%). Complications of preoperative EE and SE were observed in only 5 patients; 3 patients (3.29%) had harvested skin graft marginal necrosis, 1 patient (1.09%) had skin necrosis, and 1 patient (1.09%) had a wound infection. Only 2 patients (2.19%) reported a recurrent or residual mass during a median follow-up period of 12 months. CONCLUSIONS: 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.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation.

OBJECTIVE: To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. DESIGN: A stepwise video demonstration with narration. SETTING: A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. INTERVENTIONS: A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply CONCLUSIONS: Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.

Ethanol Embolotherapy for Cutaneous Erythema of High-Flow Vascular Malformations in the Head and Neck.

BACKGROUND: Cutaneous erythema is one of the most common signs of arteriovenous malformations (AVMs) in the head and neck region, influencing aesthetic appearance. Surgical resection of AVMs may lead to cicatrization of the skin or aggravation of the lesion. Laser treatment, although effective in improving superficial vascular lesions, cannot prevent deep AVMs from further development. OBJECTIVE: The authors propose an absolute ethanol embolization therapy that can effectively and safely eradicate the nidus with a favorable aesthetic outcome. METHODS: The authors conducted a retrospective observational study of 14 AVM patients with distinct cutaneous erythema in the head and neck region undergoing embolotherapy in a single primary care center. Symptoms before and after treatment, complications, and degree of devascularization were recorded and assessed. Changes in cutaneous redness were evaluated using a previously reported quantitative measurement. RESULTS: Complete symptomatic relief was observed in 5 patients, and major improvement was observed in 9 patients. The mean Δ a * value of the color change had a significant reduction of 6.50 ± 4.04, p < .001, indicating a remarkable remission of cutaneous erythema. CONCLUSION: Ethanol embolization is an effective and safe treatment for head and neck AVMs with excellent aesthetic outcomes and might become a potential treatment method for other superficial vascular anomalies.

Effect of direct surgical treatment in pregnancy-related uterine arteriovenous malformation.

BACKGROUND: Uterine arteriovenous malformation (UAVM) is a relatively rare but potentially life-threatening situations abnormal vascular connections between the uterine arterial and venous systems. Lack of recognized guidelines and clinic experience, there is a lot of clinic problems about diagnosis and treatment. By analyzing the clinical data of patients with pregnancy-related UAVM, we aim to confirm the safety of direct surgeries and the benefit of pretreatment (uterine artery embolization or medical therapy) before surgery, and to explore more optimal therapies for patients with pregnancy-related UAVM. METHODS: A total of 106 patients in Qilu Hospital of Shandong University from January 2011 to December 2021 diagnosed of pregnancy-related UAVM were involved in this study. Depending on whether preoperative intervention was performed, the patients were divided into direct surgery group and pretreatment group (uterine artery embolization or medical management). Clinical characteristics, operative related factors and prognosis were analyzed. RESULTS: The most common symptom of pregnancy-related UAVM was vaginal bleeding (82.5%), which could also be accompanied by abdominal pain. Pretreatments (uterine artery embolization or medical therapy) had no obvious benefit to the subsequent surgeries, but increased the hospital stay and hospital cost. Direct surgery group had satisfactory success rate and prognosis compared to pretreatment group. CONCLUSION: For pregnancy-related UAVM, direct surgery has good effects and high safety with shorter hospital stays and less hospital cost. What is more, without uterine artery embolization and other medical therapy, patients could remain better fertility in future.

Retrospective single-arm cohort study of video-assisted thoracic surgery for treatment of idiopathic peripherally located simple type pulmonary arteriovenous malformation in 23 consecutive patients.

BACKGROUND: Although case reports of video-assisted thoracic surgery (VATS) for pulmonary arteriovenous malformation (PAVM) have been published, studies analyzing more than 10 cases were limited. A retrospective single-arm cohort study was performed to investigate the efficacy of VATS in 23 consecutive patients with idiopathic peripherally located simple type PAVM. METHODS: VATS was performed for wedge resection of 24 PAVMs in 23 patients, which included 4 males and 19 females with an age range of 25 to 80 years (mean: 59.6 ± 13.0). Two patients underwent simultaneous resection of lung carcinoma, one by wedge resection and another by lobectomy. Each medical record was analyzed according to the resected specimen, bleeding volume, postsurgical hospital stay length, duration of chest tube placement, and VATS time. The distance between pleural surface/fissure and PAVM was measured on CT, and the influence of this distance on identification of PAVM was investigated. RESULTS: In all 23 patients, VATS was successfully performed, and the venous sac was included in each resected specimen. Bleeding volume was less than 10mL in all but one with 1900 mL bleeding volume due to simultaneous lobectomy for carcinoma, not wedge resection of PAVM. Postsurgical hospital stay length, duration of chest tube placement, and VATS time were 5.0 ± 1.4 days, 2.7 ± 0.7 days, and 49.3 ± 39.9 min, respectively. In 21 PAVMs with a distance of 1 mm or less, purple vessel or pleural bulge of PAVM was identified soon after insertion of a thoracoscope. In the remaining 3 PAVMs with a distance of 2.5 mm or more, additional efforts were needed for identification. CONCLUSION: VATS was found to be a safe and effective to treatment for idiopathic peripherally located simple type PAVM. When the distance between pleural surface/fissure and PAVM was 2.5 mm or more, a plan and strategy for identification of PAVM should be prepared before VATS.

Arteriovenous malformation of the prostatic median lobe: a rare case treated by transurethral resection.

Arteriovenous malformation localised to the prostate is rare. Until recently, the gold standard for diagnosis was angiography; however, this changed with the use of computed tomography and magnetic resonance imaging, which quickly became the first-line diagnostic tool. Common complaints are haematuria and lower urinary tract symptoms, for which there are no well-defined management guidelines. We present the case of a 53-year-old male patient who was treated for clotted haematuria. While the bleeding was thought to originate from an enlarged prostate, cystoscopy displayed a non-pulsatile, exophytic, active bleeding mass on the median lobe. The mass was resected transurethrally and diagnosed as arteriovenous malformation. This case shows an aberrant presentation of a vascular malformation in the prostate. The mass seemed to be constrained to a compact area without a visible plurality of arterial feeders. Since the prostate is a rare location for arteriovenous malformation, there are no well-defined treatment options. Nevertheless, the mass appears to have been successfully extracted by transurethral resection.

Management of a dural arteriovenous fistula versus arteriovenous malformation of the internal auditory canal with radiosurgery.

We present a case of a 61-year-old male who presented with an 8-month history of left hypacusis, tinnitus, and gait imbalance. MRI showed a vascular lesion in the left internal auditory canal (IAC). Angiogram showed a vascular lesion filling from the ascending pharyngeal and anterior inferior cerebellar artery (AICA) with drainage into the sigmoid sinus suggestive of either a dural arteriovenous malformation (dAVF) vs arteriovenous malformation (AVM) of the IAC. The decision was made to operate to prevent risk of future hemorrhage [1-5]. Endovascular options were not as ideal given access transarterially through the AICA would be risky, access transvenously would be difficult and it was unclear whether this lesion was a dAVF or AVM. The patient underwent a retrosigmoid approach. A tuft of arterialized vessels surrounding CN7/8 was identified and no true nidus was found so it was thought that this lesion was a dAVF. The plan was to clip the arterialized vein as is normally done for dAVF. However, there was engorgement of the vascular lesion upon clipping of the arterialized vein indicating risk of rupture if the clip was left insitu. It was too risky to drill the posterior wall of the IAC to expose the fistulous point more proximally. As a result, 2 clips were placed on the AICA branches. Postoperative angiogram showed some slowing of the vascular lesion but it was still present. Given the AICA feeder, it was decided that this lesion was a dAVF with mixed features of an AVM and the decision was made to gamma knife the lesion 3 months postoperatively. Patient underwent gamma knife targeting the dura superior to the IAC with 18 Gy at the 50 % isodose line. At 2 years follow up, the patient's symptoms improved and he remained neurologically intact. Imaging revealed complete obliteration of the dAVF. This case illustrates the step by step management of a dAVF that mimicked a true pial AVM. The patient consented to the procedure and participating in this surgical video.

Persistent cornual pregnancy mimicking uterine arteriovenous malformation: a case report.

BACKGROUND: Uterine arteriovenous malformation(AVM) refers to the abnormal direct traffic between uterine arteries and veins, which can be characterized by the imaging examination, showing increased uterine vascularity and arteriovenous shunting. However, similar imaging manifestations can also be seen in a variety of conditions including retained production of conception, gestational trophoblastic disease, placental polyp, and vascular neoplasm. CASE PRESENTATION: Here we present a case of a 42-year-old woman who was suspected of suffering uterine AVM indicated by Doppler sonography and magnetic resonance imaging but was finally diagnosed with a persistent ectopic pregnancy located on the right uterine corner by pathology after laparoscopy. She recovered well after surgery. CONCLUSION: Uterine AVM is a rare and serious condition. In general, it presents special radiological manifestations. However, when complicated with other diseases it can also be distorting. Standardized diagnosis and management are important.

Laparoscopic surgery for rectal cancer with a coexisting Retzius shunt and inferior mesenteric arteriovenous malformation: A case report.

A coexisting short-circuit from the inferior mesenteric vein (IMV) to the inferior vena cava, known as a Retzius shunt, and arteriovenous malformation (AVM) of the inferior mesentery are extremely rare conditions. We encountered a case of rectal cancer with coexisting Retzius shunt and inferior mesenteric AVM successfully treated with laparoscopic surgery. Contrast computed tomography (CT) in a 62-year-old man with rectal cancer showed multiple dilated veins at the mesenterium of the descending sigmoid colon. These dilated veins were connected between the IMV and the left renal vein. A diagnosis of Retzius shunt was made, and laparoscopic low anterior resection with lymph node dissection was performed. A pathological examination of the colonic mesenterium revealed AVM communicating with the dilated IMV and Retzius shunt. The preoperative evaluation of aberrant vessels by three-dimensional CT is particularly useful for patients with vascular malformations to ensure safe laparoscopic surgery.

The Shunt of It.

Pulmonary arteriovenous malformations (PAVMs) are rare and most often identified in patients with hereditary hemorrhagic telangiectasia (HHT). We describe a patient with severe hypoxemia and orthodeoxia with imaging findings consistent with PAVMs. Resected lung pathologic findings confirmed the presence of numerous microscopic vascular abnormalities within the right lower lobe that was consistent with diffuse pulmonary arteriovenous shunts. Family history was negative for HHT but was positive for pulmonary arterial hypertension (PAH) in two second-degree relatives. A vascular malformation gene panel was negative for genes that commonly are associated with HHT but identified a pathogenic variant in the gene encoding bone morphogenetic protein receptor-2 (BMPR2 p.Cys123∗). Pathogenic variants in BMPR2 are a well-known cause of hereditary PAH; there have been several reports to date of patients with PAVMs and PAH. However, this is the first patient to be reported with a pathogenic variant in BMPR2 to have PAVMs in isolation.

Colorectal Arteriovenous Malformations causing Prolonged Bleeding were Managed Successfully by Laparoscopic Low Anterior Resection with Sphincter Preservation: A Case Report.

Gastrointestinal arteriovenous malformations (AVMs) are a rare disease. Sigmoid-anorectal AVM has only been reported in a few cases. The condition is usually detected when patients have gastrointestinal bleeding complications. The diagnosis and treatment of colorectal AVMs are still challenging. This paper presents a case of an Asian 32-year-old female patient admitted to hospital because of lower gastrointestinal bleeding lasting 17 years. The patient was diagnosed with sigmoid-rectal arteriovenous malformation and failed with other medical treatments. The damaged gastrointestinal tract was removed by a laparoscopic low anterior resection. The results were positive after a three-month follow-up; the bleeding was resolved, and the anal sphincter function was intact. Laparoscopic low anterior resection is a safe, less invasive, and effective approach for managing patients with digestive tract bleeding due to extensive colorectal AVM and preservation of the anal sphincter.