Therapeutic approach to arteriovenous malformations of the tongue.

Arteriovenous malformations (AVM) are developmental errors with a high complication rate because they are hemodynamically active. The aim of our study is to evaluate management of the rare subgroup of tongue AVM. From 1982 to 1994, 25 patients with AVM of the tongue presented to our department. All patients were discussed in our multidisciplinary staff consultation and were treated by embolization, surgery, or were followed-up clinically with no intervention. Thirteen patients were asymptomatic in a hemodynamically quiescent phase and did not require any kind of intervention. The 12 others underwent embolization procedures following which 6 became stable, 2 had complementary surgery, 1 was lost to follow-up, 1 had two minor bleeding episodes without the need for hospitalization, and 2 were improved. Arteriovenous malformations of the tongue must be followed clinically and treated only if they become active. Permanent embolization with a polymerizing liquid administered through supra-selective catheterization or by direct puncture of the malformation is recommended.

The current management of cervico-cephalic venous malformations.

Venous malformations are often detected at birth and progressively increase in size if not treated. They can have severe aesthetic and functional consequences. Our purpose is to evaluate therapeutic results with Ethibloc. From 1982 to 1994, we have been using Ethibloc injections under fluoroscopic control in a group of 421 patients with malformations in cervicofacial veins. The diagnosis was made on the basis of clinical examinations as well as by using CT and MRI. In addition, 40 patients had a diagnostic angiogram. The therapeutic procedure consisted of direct puncture and opacification of venous the basis of lakes before injection of Ethibloc. Two hundred patients have been analyzed. In 139 patients treated with Ethibloc alone, the venous malformations were reduced significantly in size in 64%, while we obtained good results in 67% of the 61 patients treated with a combined procedure (Ethibloc followed by surgical excision). In those, Ethibloc effectively prevented extensive blood loss during surgery and delineated the malformations. Minor complications occurred such as fever or aseptic superficial abscesses. Ethibloc is safe, has no neurotoxicity, is efficient can be repeated many times and facilitates surgery. It must be used as the therapy of choice in venous malformations.

[Disabling calf pain in the context of venous angiodysplasia: Contribution of dynamic exploration]. / Douleur du mollet invalidante dans le cadre d'une angiodysplasie veineuse: apport des explorations dynamiques.

We report the case of a 25-year old woman presenting with disabling pain of the left calf, associated with lower left limb angiodysplasia. Dynamic testing (duplex scan and phlebography) showed a popliteal vein ectasia, with reflux into an incompetent lesser saphenous vein: the venous drainage of this ectasia was an embryonic femoropopliteal vein going to the profunda femoris vein. As long as patency and competence of deep veins and of the superficial femoral vein were confirmed by dynamic testing with compressions, curative surgery was considered: en-bloc resection of lesser saphenous vein and of embryonic femoropopliteal vein combined with lateral suture of the popliteal vein. One-year follow-up confirms the absence of recurrent symptoms. Dynamic testing allows safe surgical therapy of persisting embryonic abnormalities associated with incompetent veins, in cases where such testing clearly demonstrates that a sufficient venous drainage of the affected limb will be provided after surgery.

Vertebral arteriovenous fistulas: a study of 49 cases and review of the literature.

The experience is reported with 50 vertebral fistulas treated by the authors in a joint radiological and surgical team. Of the 28 fistulas that were traumatic, 18 occurred after incidental iatrogenic puncture, and 22 were spontaneous, of which four presented in patients displaying angiographic features of fibromuscular dysplasia. Eleven patients were operated on and 33 had endovascular treatment. In nine patients who were either symptom-free or in poor health, no treatment was advised. The fistula was occluded in 38 (93%) of the treated patients, and the vertebral artery patency was preserved in 32 (78%). A total of 224 published cases were reviewed: 152 were traumatic, most after a penetrating injury; 72 were spontaneous, with three age peaks (at 7, 26 and 52 years). Treatment has evolved considerably and endovascular occlusion is now the treatment of choice, surgery being reserved for specific indications.

Percutaneous embolization with Ethibloc of lymphatic cystic malformations with a review of the experience in 70 patients.

Cystic lymphatic malformations (CLM) are superficial vascular hemodynamically inactive malformations of the lymphatic compartment. We propose a new approach which uses a sclerosing agent as an alternative to surgical resection. In the past nine years we treated 70 patients with CLM. Fifty-five percent were younger than five years of age with a male preponderance and most (80%) of the CLM were located in the maxillofacial region. They usually presented with functional impairment from the mass effect; others had infections, bleeding, or inflammation. The CLM were injected under fluoroscopic control with a sclerosing agent, Ethibloc, which dries up the pockets and reduces the mass. On follow-up the results were good in 62%, unchanged in 5%, and continued progression in 20%. Fifteen percent underwent surgery failures (24%) occurred in mixed forms of cystic and cellular lymphangiomas. Complications were minors. Percutaneous embolization is useful for CLM, with minimal risk, absence of scar, and it avoids surgery. It should be the first line of treatment for these lesions.

Endovascular treatment of arteriovenous fistulas arising from branches of the subclavian artery.

PURPOSE: The goal of this study was to evaluate the role of endovascular techniques in the treatment of arteriovenous fistulas (AVFs) in the subclavian region. PATIENTS AND METHODS: Since 1984 six patients with AVFs arising from branches of the subclavian artery have been treated. All AVFs were of iatrogenic origin (five venous punctures and one pacemaker insertion). Two patients had cardiac insufficiency, three had a bruit, and one had upper extremity venous hypertension. Angiographically, four of the AVFs were located on the thyrocervical trunk and two were on the internal mammary artery. RESULTS: All fistulas were treated by means of endovascular occlusion with a detachable balloon, with full resolution of symptoms. One AVF recurred after a balloon deflated prematurely. The patient was treated again and was subsequently cured. No other complications were associated with treatment. CONCLUSION: Endovascular balloon occlusion of AVFs in the subclavian region is a simple, effective, and safe method that eliminates the need for surgery. It should be the method of choice for treatment of these lesions.

[Treatment of diabetic arteriopathy. Importance of transluminal angioplasty]. / Le traitement des artériopathies diabétiques. Intérêt de l'angioplastie transluminale.

Results are reported of a retrospective analysis of transluminal angioplasty (TLA) interventions in 20 diabetic patients, 16 men and 4 women, mean age 56 years (range 32 to 82 years), with 24 dilated lesions, 16 patients having insulin-dependent diabetes. In 12 cases the lesions were at the intermittent claudication stage, trophic lesions being present in 8 cases. Stenotic lesions were iliac (12 cases), superficial femoral (2 cases), popliteal (6 cases) and tibial (4 cases). One patient developed an acute occlusion following popliteal-anterior tibial recanalization, the only direct complication of the angioplasty. Angiography showed immediate satisfactory results in 22 of the 24 dilated lesions. Functional and hemodynamic improvement was a constant finding in patients with intermittent claudication, trophic lesions being healed in 4 cases (50%) the other patient showing either no change or requiring an unavoidable amputation (2 cases). These overall findings suggest that at the intermittent claudication stage no differences exist in the results of TLA when compared with a non diabetic population; inversely, in the presence of trophic disorders, the local conditions (distal bed, infection, gangrene) interfere considerably in the course of the dilatation. Transluminal angioplasty should therefore be carried out as early as possible in diabetics; arteriography should be performed as soon as even minimal claudication appears and, a fortiori, even at the onset of a trophic lesion.

[Superficial venous malformations]. / Malformations veineuses superficielles.

Mature vascular malformations of the venous compartment are haemodynamically inactive and persist throughout the patient's life. They have no systemic repercussions, except in patients with disorders of coagulation (e.g. disseminated intravascular coagulation), but they have local, cosmetic and functional repercussions. Percutaneous embolization, notably with Ethibloc, has modified their prognosis favourably. This simple and effective procedure is mainly used for superficial venous malformations of the face.

[Lymphangioma]. / Les lymphangiomes.

The term lymphangioma applies to two types of vascular malformations with very different prognoses: cystic lymphangioma, a benign and easy to treat condition, and tissue lymphangioma, a deeply infiltrating lesion the course of which is sprinkled with complications which may be severe in some locations. Therapeutic sclerosis of cystic pouches with ethibloc gives excellent results and must be performed prior to any surgical treatment, but it is ineffective in tissue lymphangioma which requires a difficult and often maiming treatment. Both types of lymphangioma may coexist, each one following a different course.

Endovascular treatment of vertebral arteriovenous fistula.

The clinical and angiographic features of 46 vertebral arteriovenous fistulas (AVFs) seen during a 12-year period (45 patients) were reviewed. Fourteen patients were asymptomatic, with vertebral AVF discovered at routine clinical examination. Specific symptoms at presentation in the other patients were tinnitus (n = 21), vertigo (n = 6), neurologic deficit (n = 3), and pain (n = 2). Of the 46 AVFs, 19 (41%) were caused by trauma and 27 (59%) were spontaneous. The fistula was found at C-1 to C-2 in 21 (46%) cases, at C-2 to C-5 in five (11%), and below C-5 in 20 (44%). Thirty-four patients (35 vertebral AVFs) were treated with the endovascular technique. Embolization was performed with latex balloons filled with contrast medium in most cases. Endovascular therapy resulted in complete occlusion in 32 cases (91%) and partial occlusion in three (9%). The vertebral artery could not be preserved in three patients. Endovascular balloon treatment of vertebral AVFs is effective in occluding the shunt, avoids general anesthesia and surgical intervention, and results in minimal morbidity. Endovascular therapy is the treatment of choice for vertebral AVF.

[Cystic lymphatic malformations of the head and neck. Role of interventional radiology]. / Malformations lymphatiques kystiques cervico-faciales. Place de la radiologie interventionnelle.

Cystic lymphatic malformations are hemodynamically inactive vascular malformations of the lymphatic compartment. Over a 9 years period, 52 patients with superficial cystic lymphatic malformations of the head and neck underwent embolization by direct injections of Ethibloc (Ethicon, Ethnon Laboratories, Neuilly/France) under fluoroscopic control. Results were graded as excellent or good in 57% of patients after embolization alone. Treatment was completed by surgery in 19% of patients. Embolization was considered a failure in 24% (12 patients), although 10 of these patients showed regression of the cystic component after embolization. This safe, efficacious percutaneous technique has emerged as the first treatment to be considered for cystic lymphatic malformations.

[Hemangiomas and superficial vascular malformations: classification]. / Hémangiomes et malformations vasculaires superficielles: classification.

Superficial vascular malformations of the face, trunk and limbs are better known today, and they can be divided up into simple and complex vascular malformations. Simple vascular malformations may form five major categories: immature hemangiomas of infants, port-wine stains, capillarovenous angiodysplasias, and arteriovenous fistulae and malformations. Complex angiodysplasias are systematized (Sturge-Weber and Bonnet-Dechaume-Blanc syndromes, Cobb's metameric angiomatosis, Klippel-Trenaunay and Parkes Weber's syndromes) or disseminated (Weber-Osler-Rendu disease and blue rubber-bleb nevus syndrome). Various modalities of treatment may be contemplated, according to the type of malformations, and an interdisciplinary consultation is essential to decide whether a watch-and-wait policy, a physical method (laser), embolization, fibrosing injections, vascular, maxillofacial or plastic surgery, or a successive combination of various techniques should be resorted to.

[Exploration strategy for superficial vascular malformations]. / Stratégie d'exploration des malformations vasculaires superficielles.

Transillumination of cystic lymphangiomas, MRI of venous vascular malformations, pulsed Doppler and arteriography of arteriovenous malformations, echo-Doppler and radiomeasurement of malformations in the lower limbs are key examinations in the exploration strategy for superficial vascular malformations.

[Venous vascular malformations and their treatment with Ethibloc]. / Les malformations vasculaires veineuses et leur traitement par Ethibloc.

The use of Ethibloc must be contemplated as a first-intention treatment for venous malformations of the face. This sclerosing agent has transformed the functional, esthetic and psychological prognosis for these vascular malformations.

[Cystic lymphatic malformations and their treatment]. / Les malformations lymphatiques kystiques et leur traitement.

Lymphangiomas are remarkably well amenable to treatment with direct aspiration then embolization with a sclerosing agent derived from maize: Ethibloc.

MR imaging of head and neck vascular malformations.

Between 1980 and 1990, 150 patients with cervicofacial vascular malformations were studied at the authors' institution with computed tomography, plain radiography, and angiography. Since 1989, 34 of these patients have also undergone magnetic resonance (MR) imaging. Capillary-venous hemangiomas seem to be the best indication for the adjunctive use of MR imaging. The venous pouches, characteristic of this type of lesion, cause elevated signal intensity, well seen on the T2-weighted images. Excellent fat and muscle differentiation with MR imaging allows appreciation of the depth of extension of these lesions and their delimitation from normal tissue. Arteriovenous malformations (AVMs) are characterized by serpentine signal voids, indicative of the high flow rate of these lesions. Delimitation of the AVM nidus in the midst of the afferent and efferent dilated vessels is often difficult. Study of immature angiomas with MR imaging should be restricted to lesions in specific locations (eg, orbital, laryngeal). Lymphatic malformations showed either tissular or cystic signal intensity changes. MR imaging does not replace other studies but represents an important complementary study for the delineation and diagnosis of deep extensions of vascular malformations, allowing better planning of therapy.

Femoral infarction following intraarterial chemotherapy for osteosarcoma of the leg: a possible pitfall in magnetic resonance imaging.

Bone infarction of the distal femur is reported in two patients with osteosarcoma of the leg (1 tibia, 1 fibula) treated by preoperative chemotherapy including intraarterial chemotherapy (IAC) by Cis-platinum. Both patients were examined by magnetic resonance imaging before chemotherapy and again prior to limb salvage surgery. The location of these lesions in the distal femur must suggest bone infarction especially if the tumor has decreased in size under treatment.

[Pseudo-Kaposi syndromes of vascular origin]. / Les pseudo-syndromes de Kaposi "d'origine vasculaire".

Pseudo-Kaposi's Sarcoma with vascular disease concern mainly acroangiodermatitis described by Mali--(with chronic venous insufficiency)--, arteriovenous malformations with angiodermatitis described by Stewart and Bluefarb, and pseudo-Kaposi's Sarcoma occurring after placement of arteriovenous shunt for hemodialysis. Search for relation ships between classical Kaposi's Sarcoma and new AIDS Kaposi's Sarcoma explains new interest devoted to Pseudo-Kaposi's Sarcoma.

[Superficial vascular (arterial and venous) malformations: clinical aspects and complementary tests]. / Malformations vasculaires superficielles (artérielles et veineuses): aspects cliniques et examens complémentaires.

A simple and precise classification has been established during a ten-year international cooperation. There are two major groups: hemangiomas, always regressive; and vascular malformations, which never regress; they grow, throughout life, to varying degrees. Management of vascular malformations has been clearly defined. Capillary malformations do not require examination, unless they are associated with other anomalies, such as hypertrophic underlying bone, or the leptomeningeal vascular anomaly of the Sturge-Weber syndrome. Venous type malformations are diffuse, and consist of entirely anomalous channels, with low flow. CT scan and MRI clearly demonstrate the extent of tissue involvement in venous malformations; for these slow-flow malformations the evaluation is performed without resorting to invasive diagnostic techniques: phlebography is rarely performed, and arteriography is unnecessary. Arteriovenous malformations are dangerous high-flow vascular malformations, leading to skin ischemic necrosis, and congestive cardiac failure. Arteriography shows enlarged tortuous arteries, with arteriovenous shunting, and early venous drainage. CT scan and MRI show the deep components of the lesions. Doppler ultrasound evaluation is used to follow the course of the disease.