Treatment Effectiveness and Recurrence of Extracranial Arteriovenous Malformations Following Surgical Operations: A 15-Year Retrospective Cohort Study.

BACKGROUND: At present, there is no golden standard for treatment of extracranial arteriovenous malformations (AVMs) and recurrence remains a major challenge with limited available evidence on the associated factors. This study aimed to evaluate the effectiveness of surgical treatment options, in terms of size reduction, symptoms, and early recurrence in patients treated surgically for AVMs. METHODS: A retrospective cohort study was conducted to evaluate patients with AVMs following surgical treatment in 2 centers from 2005 to 2020. Posttreatment lesion size and symptoms, as well as recurrence, were assessed. Multiple regression analysis was performed to identify factors associated with recurrence. RESULTS: Forty-four surgical treatment cases in 31 patients were assessed with a mean follow-up duration period of 67.9 ± 39.5 months. Treatment included total resection in 26 cases (59.1%) and partial resection 18 (40.9%), with free flap coverage used in 19 cases (43.2%). No acute exacerbation following treatment was observed in our cohort. Total resection significantly reduced posttreatment lesion size ( P < 0.001), symptoms ( P < 0.001), and recurrence (20.0%, P = 0.03). The recurrence rate was significantly higher after partial resection (73.7%, P = 0.03). Total resection was identified as an associated factor for significantly reduced AVM recurrence (odds ratio: 0.12; 95% confidence interval: 0.03, 0.52). However, the use of free flaps did not significantly reduce recurrence, post treatment size or improve AVM symptoms. CONCLUSIONS: Total resection is the optimal treatment for AVMs. Free flaps are useful in covering large defects but the regulative effect of free flap remains controversial.

Factors That Influence the Speed and Completion of Double Balloon Enteroscopy in Patients with Arteriovenous Malformations.

BACKGROUND: Double balloon enteroscopy remains a resource and time-intensive procedure that is not available in many endoscopy units. AIMS: We aimed to identify variables impacting the speed and completion of double balloon enteroscopy. METHODS: We retrospectively reviewed 550 patients. Using a mean time and distance for both the antegrade and retrograde approach, we determined the procedure speed and assessed factors that influenced it. In addition, we assessed the factors that contributed to a complete double balloon enteroscopy. RESULTS: A total of 386 antegrade and 164 retrograde double balloon enteroscopies were performed. Greater than 10 AVMs requiring treatment was a negative predictor (AOR 0.25, CI 0.11-0.51, p < 0.001), whereas age greater than 60 years (AOR 2.66, CI 1.18-6.65, p = 0.025) was a positive predictor of a fast antegrade enteroscopy. For retrograde, prior abdominal surgery was the only factor that trended to significance (AOR 0.38, CI 0.14-0.99, p = 0.052). A total of 120 combined procedures were performed. Female gender (AOR 2.62, CI 1.16-6.24, p = 0.02), history of prior abdominal surgery (AOR 0.31, CI 0.13-0.70, p = 0.006) and Boston bowel pre-preparation score of greater than 6 (AOR 4.50, CI 1.59-14.30, p = 0.006) were the only significant predictors of a complete procedure. CONCLUSION: By applying double balloon enteroscopy speed, a novel method of measuring procedure efficiency, we were able to more reliably identify the factors that will negatively impact the speed and success of the procedure.

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.

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.

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.

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.

How I do it: surgery for spinal arteriovenous malformations.

BACKGROUND: Spinal arteriovenous malformations (AVM) are rare lesions. They may present with intramedullary hemorrhage or edema, often inducing severe neurological deficits. Active treatment of spinal AVMs is challenging even for experienced neurosurgeons. METHOD: Anticipation of anatomy and AVM angiocharacteristics from preoperative imaging is key for successful treatment. Information gathered from MRI and DSA has to be then matched to intraoperative findings. This is a prerequisite for reasonably safe and structured lesion removal. CONCLUSION: We provide a structured approach for surgical treatment of spinal AVMs, supplemented by high-resolution video and imaging material.

Reversible splenial lesion after surgery for distant arteriovenous malformation: a case report.

Isolated lesions of the corpus callosum are rare and may represent permanent but also transient responses to various pathology termed "reversible splenial lesion syndrome" (RESLES) when in light of relevant clinical presentation. We present the first case of the RESLES after elective surgery for distant arteriovenous malformation (AVM), followed by a slight speech disturbance and MRI verified small, oval, well-circumscribed area of apparent cytotoxic edema in the center of the corpus callosum splenium, which completely resolved within 15 days. Surgery for AVM is followed by the complex adaptation to a new vascular pattern, RESLES might develop, and should be suspected.

Treatment of Challenging Extracranial Arteriovenous Malformations: A Single-Center Experience and Literature Review.

ABSTRACT: Extracranial arteriovenous malformation (AVM) is a high-flow congenital vascular malformation, where direct communication between the arteries and veins impedes perfusion of capillary beds and causes disfigurement of the affected tissue. Surgery and endovascular therapy are currently the main treatment for extracranial AVMs. Nevertheless, management of complex cases is sometimes challenging because of severe complications such as refractory ulceration, life-threatening bleeding, and even cardiac insufficiency. Here, we reviewed the development and potential treatment for extracranial AVMs and shared our single-center experiences of diagnosis and treatment of this challenging disease.

OptImal Gamma kNife lIghTnIng sOlutioN (IGNITION) score to characterize the solution space of the Gamma Knife FIP optimizer for stereotactic radiosurgery.

OBJECTIVES: The objective of this study is to evaluate the user-defined optimization settings in the Fast Inverse Planning (FIP) optimizer in Leksell GammaPlan® and determine the parameters that result in the best stereotactic radiosurgery (SRS) plan quality for brain metastases, benign tumors, and arteriovenous malformations (AVMs). METHODS: Thirty patients with metastases and 30 with benign lesions-vestibular schwannoma, AVMs, pituitary adenoma, and meningioma-treated with SRS were evaluated. Each target was planned by varying the low dose (LD) and beam-on-time (BOT) penalties in increments of 0.1, from 0 to 1. The following plan quality metrics were recorded for each plan: Paddick conformity index (PCI), gradient index (GI), BOT, and maximum organ-at-risk (OAR) doses. A novel objective score matrix was calculated for each target using a linearly weighted combination of the aforementioned metrics. A histogram of optimal solutions containing the five best scores was extracted. RESULTS: A total of 7260 plans were analyzed with 121 plans per patient for the range of LD/BOT penalties. The ranges of PCI, GI, and BOT across all metastatic lesions were 0.58-0.97, 2.1-3.8, and 8.8-238 min, respectively, and were 0.13-0.97, 2.1-3.8, and 8.8-238 min, respectively, for benign lesions. The objective score matrix showed unique optimal solutions for metastatic lesions and benign lesions. Additionally, the plan metrics of the optimal solutions were significantly improved compared to the clinical plans for metastatic lesions with equivalent metrics for all other cases. CONCLUSION: In this study, FIP optimizer was evaluated to determine the optimal solution space to maximize PCI and minimize GI, BOT and OAR doses simultaneously for single metastatic/benign/non-neoplastic targets. The optimal solution chart was determined using a novel objective score which provides novice and expert planners a roadmap to generate the most optimal plans efficiently using FIP.

Fontan completion of a 10-year-old Kawashima patient with extensive arteriovenous malformations: consideration for a lobectomy.

A significant contributing factor to the progression of late cyanosis in individuals undergoing Kawashima operation is pulmonary arteriovenous malformations. Following the Fontan procedure, arteriovenous malformations may regress. However, in cases with extensive malformations causing severe cyanosis, lobectomy can also be a possible treatment approach. Thereby, we present our two-step treatment strategy in a late Fontan completion complicated by arteriovenous malformations in a Kawashima patient.

Chronic encapsulated intracerebral hematomas: a systematic review.

BACKGROUND: Chronic encapsulated intracerebral hematoma (CEICH) is a rare type of intracerebral hematoma (ICH) with peculiar radiological features and presenting as subtle slow-growing lesion exerting mass effect. We performed a systematic review of the literature focused on diagnosis and management of patients affected by CEICH. MATERIAL AND METHODS: A literature search according to the PRISMA statement was conducted using PubMed and Scopus databases and pertinent Mesh terms. All papers that reported intraventricular CEICH, or CEICH cases treated conservatively or by CT-guided needle aspiration were not included in this study. A total of 40 papers were included in this review, with 58 patients (38 males and 20 females) and a mean age of 41.44 ± 20.05 years (range 1-80). RESULTS: Neurological symptoms of onset include those related to an increase in intracranial pressure (ICP) in 28/58 cases (48.2%), seizures in 17/58 cases (29.3%), motor deficits in 14/58 cases (24.1%). The most frequent localization is atypical in 45/58 cases (77.6%). Surgical approach is not specified in 21/58 cases (36.2%), craniotomy was performed in 31/58 cases (53.4%), craniectomy in 5/58 cases (8.6%) and only in one case (1.7%) an endoscopic approach was performed. CEICH are usually located in an atypical site. CONCLUSIONS: There is not an association with anticoagulants and antiplatelets intake. Arteriovenous malformation is the most frequent cause. Surgery is suggested, and craniotomy is the most used approach even if further investigation should be directed to analyze the efficacy of endoscopic approach of these lesions, which may show favorable outcome.

Intraventricular haemorrhage due to re-ruptured arteriovenous malformation cleared with tissue plasminogen activator administered through a pre-existing ventriculoperitoneal shunt.

In the context in intraventricular haemorrhage (IVH), intrathecal thrombolytic agents administered in conjunction with extraventricular drainage have been demonstrated to clear larger volumes of blood and reduce mortality rates. However, patients with arteriovenous malformations (AVM) have been mostly excluded from clinical trials. We describe a patient with hydrocephalus secondary to a ruptured AVM who was treated via external ventriculostomy, which was subsequently converted to a ventriculoperitoneal shunt (VPS). Eight months later, the AVM re-ruptured, causing IVH and rendering the patient comatose. Taking into consideration the patient's poor outlook, a single dose of intraventricular tissue plasminogen activator (t-PA) was administered through the shunt reservoir. The shunt maintained its function and the patient's condition ultimately improved. This impressive case demonstrates the utility of t-PA administered through an existing VPS in the setting of IVH due to ruptured AVM, highlighting its lifesaving potential in the appropriate patient and overall decrease in the cost of care by mitigating the need for shunt revision.

Intraspinal canal platform system for coil embolization of anterior spinal artery aneurysm associated with spinal cord arteriovenous malformation: a case report and literature review.

BACKGROUND: The prognosis for spinal artery aneurysms associated with spinal cord arteriovenous malformations (AVMs) is poor because of the high rupture rate of aneurysms. However, endovascular treatment remains technically difficult because the catheter system must be constructed via the small-caliber anterior spinal artery (ASA) or posterior spinal artery (PSA), which feeds functionally eloquent spinal cord. A 2.6F Carnelian HF-S microcatheter (Tokai Medical Products, Aichi, Japan) has been specifically designed to assist a 1.6F Carnelian MARVEL S microcatheter (Tokai Medical Products) as a small-profile 'platform catheter' close to the target lesion. Here we present a prenidal ASA aneurysm treated using a 2.6F Carnelian HF-S microcatheter as an intraspinal canal platform catheter and review related literature. CASE PRESENTATION: A 50-year-old man presented with a subarachnoid haemorrhage due to cervical spinal cord AVM. Diagnostic vertebral angiography revealed the AVM supplied by the PSA originated from the right C2 segmental artery and ASA arising from the right V4 segment. Superselective angiography for each feeder was achieved through a 2.6F Carnelian HF-S microcatheter, and a prenidal ASA aneurysm was diagnosed, which was clinically consistent with haemorrhagic origin. A 1.6F Carnelian MARVEL S microcatheter was cannulated into the aneurysm through the 2.6F Carnelian HF-S microcatheter positioned at the ASA. The aneurysm coiling was successfully performed without system instability or periprocedural complications. CONCLUSIONS: Only a few cases have described endovascular treatment for spinal artery aneurysms. To date, no reports have been published regarding the use of an intraspinal canal platform catheter to treat spinal artery aneurysms. A 2.6F Carnelian HF-S microcatheter served as a useful intraspinal canal platform catheter for coil embolization of the ASA aneurysm. This system can provide excellent accessibility and controllability for endovascular treatment of spinal artery lesions.

Free superficial circumflex iliac artery perforator flow-through flap transfer for reconstruction after excision of arteriovenous malformations of the hand: A case report.

The management of arteriovenous malformations (AVMs) of the hand remains challenging. When radical excision results in large defects of both soft tissue and vessels, flow-through flap transfer is useful; however, flow-through flap options for hand and digit reconstructions are limited. Herein, we describe the use of a superficial circumflex iliac artery perforator (SCIP) flow-through flap after excision of an AVM of the hand. A 44-year-old female patient with an AVM of the hand required simultaneous reconstruction of soft tissue, vascular, and bone defects after radical excision of vascular lesions. A 6 × 15 cm SCIP flow-through flap was transferred, and flow-through vascular reconstruction was performed with flap vessels: the deep branch of the superficial circumflex iliac artery, superficial inferior epigastric artery, and superficial circumflex iliac vein. In addition, three bone holes in the proximal phalanx of the index finger were filled with iliac bone grafts. The postoperative course was uneventful, with good functional results 1 year after surgery. An SCIP flow-through flap is an option for reconstruction after excision of AVMs of the hand because of its advantages, including minimal donor-site morbidity, availability of multiple vessels suitable for anastomosis with hand vessels, and simultaneous availability of iliac bone grafts.

Extensive severe intraorbital arteriovenous malformations: report of a rare laser complication and successful management.

Arteriovenous malformations (AVMs) are rare congenital errors of vascular morphogenesis, characterised by abnormal direct communications between arteries and veins, bypassing the normal capillary bed. Apart from the central nervous system, typical locations include the head and neck, and less frequently limbs, trunk or internal organs. AVMs of the head and neck often become clinically evident and symptomatic only in later childhood and are characterised by a history of variable growth, sometimes leading to large, deforming, pulsating masses with a propensity to massive haemorrhage. Therapeutic strategy is based on selective embolisation, surgical excision, or a combination of both. Radical surgical excision of local AVMs is the only effective treatment but it may be mutilating, especially for AVMs of the head and neck. Laser therapy represents a good option to treat the cutaneous aspects of AVMs nevertheless, its efficacy is limited. To the date, pharmacological therapy for AVMs is still on debate due to its controversial outcomes as it seems not as effective as other treatments and usually requires a longer course of application. However, pharmacological therapy could be useful in selected patients and for AVMs nonresponsive to traditional treatment, allowing them to obtain acceptable results without serious complications. This paper reports the case of a serious laser complication of extensive intraorbital AVM successfully treated by local reconstruction and topical pharmacological treatment.

Implant Therapy in the Rehabilitation of Treated Mandibular Arteriovenous Malformations.

Mandibular arteriovenous malformations are rare congenital malformations that require multidisciplinary care. Implant-supported rehabilitation of significant bone defect after embolization and resection is poorly described in the literature. We present the case of a 24-year-old patient with a right-sided mandibular arteriovenous malformation diagnosed after massive hemorrhage and treated by embolization and resection surgery. Implant rehabilitation was carried out 9 years later with a prior bone graft through iliac extraction and 3 short implants. Implant survival rate and patient satisfaction were evaluated at 3 years postplacement. Arteriovenous malformations treatments frequently result in bone defects that are difficult to reconstruct because of probable unstable vascularization due to embolization. The presence of osteosynthesis material and artifacts at the radiological level complicates implant planning due to the lack of visualization of the inferior alveolar nerve or artery and necessitates the placement of low-height implants. Osteointegration in contact with embolization products should be monitored. The creation of a case series could be of interest in order to better understand implant treatment for patients with a history of arteriovenous malformations.

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.

Scalp arteriovenous malformations - 20 years of experience in a tertiary healthcare centre.

BACKGROUND: Scalp arteriovenous malformations (SAVM) are extremely uncommon vascular malformations, with only ~200 cases published in the English language in the past years. The objective of the present study was to describe the experience of a single reference service in neurosurgery. METHODS: This is a descriptive and retrospective study conducted at our institution, which included cases of SAVM treated between 2001 and 2022. All information were extracted from the medical records of our institution. Patient confidentiality was preserved. Furthermore, an illustrative case has been described in detail. RESULTS: Seven patients were included. The male-to-female ratio was 2.5: 1 and the mean age was 23.3 (3-42) years. Most cases (56.4%) were spontaneous and the lesions were located in the frontal (28.7%) and parietal (28.7%) regions. All lesions were supplied by more than one feeder, with the superficial temporal and occipital arteries being the most commonly involved (71.5%). Six patients underwent preoperative embolization, and 56.4% patients had scalp necrosis. Five patients underwent surgical resection, all without recurrence and with good postoperative evolution. CONCLUSIONS: More than one artery was involved in all cases, and the properties of the involved vessel influences the approach strategy. Surgical treatment is curative, and preoperative embolization helps reduce bleeding during the surgery. Complete resection of the lesions prevents associated complications, such as bleeding or recurrence. Scalp necrosis is a frequent complication in the treatment of these lesions, and a multidisciplinary approach involving reconstructive plastic surgery should always be considered.

Reconstruction after ablative treatment of arteriovenous malformations of the head and neck.

Arteriovenous malformations are high-flow congenital vascular malformations that are characterized by abnormal connections between arteries and veins across an abnormal capillary bed. The head and neck region is the most common location for extracranial arteriovenous malformations. Due to their highly invasive, aggressive, and locally destructive nature, arteriovenous malformations are difficult to treat, and management through a multimodal, multidisciplinary approach is recommended. The mainstay of treatment is embolization and surgical excision. With the advent of genetic research, adjuvant targeted medical therapy is starting to play a larger role. Successful surgical treatment with or without embolization requires removal of the nidus. Large, focal, or diffuse lesions involving multiple anatomic areas usually necessitates surgical reconstruction. Free tissue transfer has many advantages over more conservative methods with restoration of function and contour. Herein, the authors describe the surgical treatment and reconstruction in head and neck arteriovenous malformations.