|Year : 2019 | Volume
| Issue : 1 | Page : 28-32
Foot arteriovenous malformation: A single-institutional Experience
Dheepak Selvaraj1, Edwin Stephen1, Vimalin Samuel1, Albert Kota1, Shyamkumar N Keshava2, Vinu Moses2, Munawwar Ahmed2, George Koshy2, Suraj Mammen2, Prabhu Premkumar1, P Boopalan3, Sunil Agarwal1
1 Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Orthopedics Unit III, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||8-Mar-2019|
Dr. Edwin Stephen
Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Arterio venous malformations (AVM) encompass a wide spectrum of lesions that can present as an incidental finding or produce potentially life- or limb threatening complications. The symptoms, treatment options, results, and prognosis of foot AVMs are relatively poorly known compared with AVMs involving other parts of the body. We present a series of 6 patients with foot AVM that have been managed between July 2015 and January 2018. Aims and Objectives: We plan to review the treatment of peripheral AVMs and options of treatment available. As AVM's form 10-20% of congenital vascular malformations [CVM], they remain challenging to treat and often pose threat to both life and limb due to their unpredictable nature, when compared to venous malformations [VM] or lymphatic malformations [LM]. The least common CVM's are the peripheral AVM's. Material and Methods: Six patients who presented to the Vascular Surgery OPD who underwent treatment with varying modalities are presented here. All the patients presented to our tertiary care center having received treatment elsewhere for a pulsatile swelling of the foot. Prior treatments received were mainly compression bandages / garments and in one case sclerotherapy with alcohol. Results: Two of 6 patients had been offered below knee amputations and we were able to preserve limbs on both patients. Options used were alcohol, Histacryl glue, foam sclerotherapy. Each patient is presented in detail with accompanying images. Conclusions: There is a need to increase awareness about AVM's amongst members of the medical fraternity its diagnosis and management options.
Keywords: Arteriovenous malformation, congenital, congenital vascular malformations, foot, peripheral, vascular malformation
|How to cite this article:|
Selvaraj D, Stephen E, Samuel V, Kota A, Keshava SN, Moses V, Ahmed M, Koshy G, Mammen S, Premkumar P, Boopalan P, Agarwal S. Foot arteriovenous malformation: A single-institutional Experience. Indian J Vasc Endovasc Surg 2019;6:28-32
|How to cite this URL:|
Selvaraj D, Stephen E, Samuel V, Kota A, Keshava SN, Moses V, Ahmed M, Koshy G, Mammen S, Premkumar P, Boopalan P, Agarwal S. Foot arteriovenous malformation: A single-institutional Experience. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jul 15];6:28-32. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/28/253739
| Introduction|| |
Arteriovenous malformations (AVMs) form 10%–20% of congenital vascular malformations (CVMs), remain challenging to treat, and often pose a threat to both life and limb due to their unpredictable nature when compared to VMs or lymphatic malformations (LMs).,,,,, The least common CVMs are the peripheral AVMs.,
| Diagnosis and Management|| |
All the patients presented to our tertiary care center having received treatment elsewhere for a pulsatile swelling of the foot. Prior treatments received were mainly compression bandages/garments and in one case sclerotherapy with alcohol. Two of six patients had been offered below-knee amputations, and we were able to preserve the limbs on both patients.
Following a clinical diagnosis of foot AVM, patients were counseled about the diagnosis and the need for investigations to make a plan for management.
All patients underwent a chest radiograph (CXR), electrocardiogram (ECG), magnetic resonance imaging (MRI) with MR angiography, and routine blood tests including bleeding parameters and an echocardiogram if the CXR or ECG was abnormal.
A digital subtraction angiogram (DSA) was done in five cases with alcohol sclerotherapy under conscious sedation or general anesthesia. The dose of absolute alcohol used was 0.1 ml/kg as the maximum volume per se ssion. The total amount calculated was delivered as close to the nidus as possible in aliquots (at 10-min intervals) after the application of a tourniquet below the knee. During the procedure, PaO2 was monitored. No central venous or arterial blood gas monitoring was used.
| Case Reports|| |
A 35-year-old female underwent intralesional alcohol sclerotherapy through a femoral approach followed by a transtarsal amputation and now leading a normal life [Figure 1].
|Figure 1: Case 1 – (a and b) showing preoperative status of the foot, (c) chest X-ray showing no cardiomegaly, (d and e) magnetic resonance imaging at initial workup, (f) digital subtraction angiography and alcohol sclerotherapy, (g) intraoperative picture of the transtarsal amputation, (h) postoperative picture at 7 days, (i) wound status at 21 days, (j) after 6 weeks|
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A 17-year-old male presented with ulcers on the right foot and an abscess over the anterior compartment. He underwent three sittings of alcohol sclerotherapy and the ulcers healed well. Post sclerotherapy, the skin ulceration was managed with saline dressing and compression bandages [Figure 2].
|Figure 2: Case 2 – (a) preoperative computed tomography angiography reconstruction, (b and c) diagnostic angiogram and alcohol sclerotherapy, (d) anterior compartment abscess secondary to seeding from foot ulcer, (e) healed ulcer after 3 months, (f) third sitting alcohol sclerotherapy – healing skin ulceration at 21 days|
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A 75-year-old male presented with a nonhealing ulcer and foot deformity – secondary to fibrosis. He underwent a super-selective cannulation of percutaneous transluminal angioplasty and 30% Histoacryl glue injection. A second sitting with absolute alcohol sclerotherapy was done following which the ulcer size reduced. He was inconsistent with follow-up and the ulcer recurred. The patient was offered a below-knee amputation in an attempt to reduce recurring cost on embolization, besides the foot deformity secondary to recurring fibrosis made the limb nonfunctional. The chest xray (CXR) showed a prominent aortic knuckle, and hence, an ECHO and ECG was done which were normal [Figure 3].
|Figure 3: Case 3 – (a and b) preembolization, (c) chest X-ray showing prominent aortic knuckle, (d) digital subtraction angiography and Histoacryl glue embolosclerotherapy – first sitting, (e) alcohol sclerotherapy – second sitting|
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A 32-year-old female, presented with ulceration, recurrent first-trimester abortions, and painful heel ulcer with bleeding. Post alcohol sclerotherapy, she developed severe skin necrosis leading us to offer a below-knee amputation. She refused and returned to her hometown [Figure 4].
|Figure 4: Case 4 – (a-c) magnetic resonance imaging showing diffuse arteriovenous malformation mainly involving the heel, (d and e) digital subtraction angiogram showing the heel involvement and alcohol sclerotherapy, (f) skin necrosis following alcohol injection|
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A 21-year-old male, an engineering student, presented with a foot AVM. He underwent alcohol sclerotherapy and excision of the lesion 1 week later. He is now leading a normal life with footwear modification [Figure 5].
|Figure 5: Case 5 – (a) preintervention – arteriovenous malformation of the right foot, (b and c) magnetic resonance imaging showing the arteriovenous malformation, (d) alcohol sclera therapy, (e) postsclera therapy, (f) excision of the arteriovenous malformation with rotation flap of the heel, (g) postoperative partial flap necrosis, (h) near complete wound healing in 6 weeks|
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A 28-year-old male, policeman, presented after having undergone 12 sessions of sclerotherapy (agent not known) in his home country. His MRI showed a complex, diffuse, infiltrating lesion. He was offered alcohol sclerotherapy with flap reconstruction if necessary or a below knee amputation. He was started on Sirolimus 0.8 mg/m2 to aide ulcer healing and also given foot offloading footwear. He has been planned for follow-up mid-2018, due to visa issues.
A complete list of patient profile and demographics is available in [Table 1].
| Lessons Learned|| |
- Patients need more than one session of counseling once a plan has been made. Since most have to bear the cost of treatment “out of pocket,” it is difficult for them to comprehend that there is no one definite treatment, besides a below-knee amputation. Convincing them that we could try giving them a heel to walk could require multiple sessions of intervention with embolosclerotherapy spread out over a period of time, thereby, minimizing the procedural risk. Patient's expectations often are often unrealistic, therefore, increasing the need for counseling
- Interventions should be done under general anesthesia
- Occupation and age of the patient plays a significant role in deciding management options. Our patients presented late in all cases
- It is advisable to use Luer-Lock glass syringes when using alcohol as the piston moves more easily
- The interventional team should wear protective eye gear to significantly reduce contact with absolute alcohol
- A transient rise in heart rate may be noted when sclerosant alcohol is injected, indicates inadequate analgesia and chemical toxicity of the alcohol
- Absolute alcohol when used in aliquots, at a maximum dosage of 0.1 ml/kg per se ssion, will reduce the risk of pulmonary hypertension and requirement of invasive monitoring (e.g., Swan–Ganz catheter)
- Skin ulceration at sites away from the source of injection does occur, as happened in case 2. Heel AVMs are more likely to have skin necrosis
- Recurrent abortions could be a result of a hyperdynamic circulation
- Have a multidisciplinary team (vascular surgeon, interventional radiologist, pediatrician, hemoncologist, orthopedician, plastic, and reconstructive surgeon) to improve the outcomes
- Patients have to travel long distances to meet specialists, and this makes frequency of follow-up a problem. Hence, we have offered repeat sclerotherapy within a week of the previous intervention.
|Figure 6: Case 6 – (a and b) nonhealing ulcer at presentation, underlying arteriovenous malformation and (c and d) magnetic resonance imaging showed a complex, diffuse, infiltrating lesion|
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| Future|| |
AVM is neither a VM nor LM, and it is fundamentally different in its management and prognosis.
Hence, there arises the need to increase the awareness about AVMs among members of the medical fraternity its diagnosis and management options. This would help with follow-up of patients that travel long distances.
None of our patients could afford NBCA or Onyx. Histoacryl glue.
Sodium tetradecyl sulfate along with the above substances is associated with distal embolization, vascular occlusion, and skin necrosis.
There is a need to find a safer and cheaper option to “attack” the nidus.
We suggest the use of drugs such as sirolimus and thalidomide, in patients not keen for intervention or between interventions, especially in a scenario like ours where a patient's follow-up can be a problem. These medications prevent or reduce neovascular stimulation as a result of collateral formation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Our team would like to put on record our heartfelt gratitude for the immense contribution of Prof. B. B. Lee, in helping us understand these complex cases, sharing literature, advice on the management of complex cases, and his comments on this paper.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lee BB, Kim DI, Huh S, Kim HH, Choo IW, Byun HS, et al.
New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation. J Vasc Surg 2001;33:764-72.
Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS, et al.
Management of arteriovenous malformations: A multidisciplinary approach. J Vasc Surg 2004;39:590-600.
Lee BB. Arteriovenous malformation. In: Zelenock, Huber, Messina, Lumsden, Moneta, editors. Mastery of Vascular and Endovascular Surgery. Ch. 76. Philadelphia: Lippincott, Williams and Wilkins Publishers; 2006. p. 597-607.
Lee BB, Lardeo J, Neville R. Arterio-venous malformation: How much do we know? Phlebology 2009;24:193-200.
Lee BB, Laredo J, Deaton DH, et al
. Arteriovenous malformations: Evaluation and treatment. In: Gloviczki P, editor. Handbook of Venous Disorders: Guidelines of the American Venous Forum. 3rd
ed., Ch. 53. London, UK: A Hodder Arnold; 2009. p. 583-93.
Lee BB, Villavicencio L. General considerations: Arteriovenous anomalies. In: Cronenwett JL, Johnston KW, editors. Congenital Vascular Malformations: Ruth-Erford's Vascular Surgery. 7th
ed., Ch. 68. Sec. 9. Philadelphia, PA, USA: Saunders Elsevier; 2010. p. 1046-64.
Tasnádi G. Epidemiology and etiology of congenital vascular malformations. Semin Vasc Surg 1993;6:200-3.
Cho SK, Do YS, Shin SW, Kim DI, Kim YW, Park KB, et al.
Arteriovenous malformations of the body and extremities: Analysis of therapeutic outcomes and approaches according to a modified angiographic classification. J Endovasc Ther 2006;13:527-38.
Shin BS, Do YS, Lee BB, Kim DI, Chung IS, Cho HS, et al.
Multistage ethanol sclerotherapy of soft-tissue arteriovenous malformations: Effect on pulmonary arterial pressure. Radiology 2005;235:1072-7.
Lee BB, Baumgartner I, Berlien HP, Bianchini G, Burrows P, Do YS, et al.
Consensus document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management. Int Angiol 2013;32:9-36.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]