EJVES Extra 23 (2012) e11ee13

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Short Report

Multidisciplinary Approach to a Peripheral Arteriovenous Malformation

K. Igari*, T. Kudo, T. Toyofuku, M. Jibiki, Y. Inoue
Division of Vascular and Endovascular Surgery, Department of Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The management of arteriovenous malformations (AVMs) remains challenging because of
Received 28 October 2011 their unpredictable behaviour and high recurrence rate.
Accepted 15 November 2011 Report: This report describes the case of a 37-year-old female with AVM in her left thigh. After twice
embolotherapy, the AVM was recognised to be resectable, and intra-operative embolisation was per-
formed to block the blood ow into the nidus of the AVM. The malformation was completely resected
Keywords:
with minimal blood loss.
Arteriovenous malformation
Discussion: Multidisciplinary treatment that integrates surgical therapy with embolotherapy is essential
Embolotherapy
Surgical resection
to manage AVMs and to improve the results of treatment, with limited morbidity and no recurrence.
2011 European Society for Vascular Surgery. Published by Elsevier Ltd.
Open access under CC BY-NC-ND license.

Introduction
Arteriovenous malformations (AVMs) are rare congenital
lesions. Complete eradication of the nidus of an AVM is the only
potential cure.1 However, surgical resection is often difcult, and
recurrence of the AVM is common with incomplete resection.
Therefore, only surgically resectable lesions should be selected for
the surgical therapy either alone or combined with various embo-
losclerotherapies either before or after the surgery. Transcatheter
embolisation now plays a signicant role in the treatment of
AVMs.2 Preoperative embolisation may be helpful prior to surgical
intervention, due to the increased risk of massive bleeding associ-
ated with such anomalies.
This report presents the case of a 37-year-old female with a large
AVM in her left thigh, which was treated with a combination of
embolisation to shrink the AVM, intra-operative embolisation to
reduce the inow to the nidus and radical resection of the AVM.
Report
A 37-year-old female presented with a large pulsatile mass in
her left thigh. Computed tomography (CT) demonstrated a large
AVM in her left thigh nourished by the branches of the deep
femoral artery (DFA), branches of the supercial femoral artery
(SFA) and collaterals (Fig. 1(a)).
DOI of original article: 10.1016/j.ejvs.2011.11.015.
* Corresponding author. Tel.: 81 3 5803 5255; fax: 81 3 3817 4126.
E-mail address: igari.srg1@tmd.ac.jp (K. Igari).
Just after admission, the mass was ruptured and bled, and an
emergency operation was performed. First, catheter arteriography
was performed, with proximal balloon occlusion of the left DFA,
which revealed the bleeding point (Fig. 2(a)); then we sutured
a part of the mass, including the bleeding point, and stopped the
bleeding. Next, we accessed the distal part of the branches of the
left DFA, and embolisation was performed by using 0.4 ml N-butyl
cyanoacrylate (NBCA) (Fig. 2(b)). The second embolotherapy was
performed 10 days later after the rst embolotherapy. The branches
of the distal part of the left SFA were also the feeding arteries, and
were embolised with a total of 0.2 ml NBCA (Fig. 2(c)). After the
second embolotherapy, magnetic resonance imaging (MRI) was
performed to evaluate the results of the embolotherapies and the
relationship with the surrounding organs. As the AVM had partially
invaded the left biceps femoris muscle (BFM), most of the AVM was
present subcutaneously in the patients left thigh. It was concluded
that the AVM lesion could be resected completely, just after blood
ow could be controlled by coil embolisation. Therefore, multidis-
ciplinary treatment was planned to include a combined endovas-
cular and surgical treatment.
During the surgery, embolisation was rst performed to control
the blood ow to the nidus. The branches of the left DFA and
superior genicular artery were embolised with platinum coils
(Guglielmi Detachable Coils, Boston Scientic, Natick, MA, USA).
Then, the AVM was excised with partial resection of the inltrated
left BFM. The AVM was completely resected with minimal bleeding,
with an estimated blood loss of 150 ml, without any need for intra-
operative blood transfusion. The defect was closed and covered
with a full-thickness skin graft. Postoperatively, the patient ach-
ieved good results of wound healing by skin grafting, and MRI
showed no arterial inow into the resected AVM (Fig. 1(b)).

1533-3167 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
doi:10.1016/j.ejvsextra.2011.11.002
e12 K. Igari et al. / EJVES Extra 23 (2012) e11ee13

further expansion of the limited role of embolotherapy as an

Figure 1. (a): Preoperative computed tomography showed a large AVM in her left
thigh, feeding from the branches of the deep femoral artery and supercial femoral
artery. (b): Postoperative magnetic resonance imaging showed no arterial inow to the
resected AVM.
adjunctive therapy for surgical resection. This approach has even
been helpful in high-risk lesions with high-ow status. Numerous
embolic materials have been developed, ranging from simple
Gelfoam pledgets to complex systems employing microcatheters
and detachable coils. We chose NBCA and platinum coils as the
embolic materials. We use NBCA to temporarily control the
bleeding, because it cannot act as a permanent agent to control
a lesion effectively as there is no evidence of permanent damage
to the endothelium.4 An ethyleneevinyl alcohol copolymer
(Onyx, Micro Therapeutics, Irvine, CA, USA) could have been
used in this case instead of NBCA. Onyx, unlike other liquid
embolic agents, does not adhere to the endothelial wall and
catheter tip.5 However, Onyx is also less adhesive than NBCA;
therefore, we preferred NBCA to Onyx in this case, which was
high-ow lesion.
Platinum coils are permanent embolic materials, which are used
to occlude the proximal site, and control blood ow. In our case, the
rst embolisation used NBCA to control the bleeding. The second
embolisation used NBCA to interrupt the connection of feeding
arteries to the nidus of the AVM, and to reduce the volume of the
AVM. After the two embolotherapy procedures, we considered the
AVM to be completely resectable; hence, a third embolotherapy
procedure was performed using platinum coils to facilitate subse-
quent surgical excision and to reduce bleeding. After that, the AVM
was totally resected with minimal bleeding.
In conclusion, the treatment of AVMs is a challenging issue for
vascular surgeons. Multidisciplinary treatment may offer better
results. To minimise the complications associated with surgery,
aggressive control of blood ow is essential, and could be amenable
with a chance of cure.

Figure 2. (a): Intra-operative angiogram showed the bleeding from the branches of the deep femoral artery. (b): After rst embolotherapy, the nidus of AVM reduced (white arrow).
(c): After second embolotherapy, angiography revealed the reduction of the nidus (black arrow).

Discussion Conict of Interest

None.
The current management of AVMs based on the new concept
Funding
of a multidisciplinary approach3 can minimise the morbidity and
None.
reduce the recurrence of the lesion. There has recently been

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References
1 Kim JY, Kim DI, Do YS, Lee BB, Kim YW, Shin SW, et al. Surgical treatment for
congenital arteriovenous malformation: 10 years experience. Eur J Vasc Endovasc
Surg 2006;32:101e6.
2 Jacobowitz GR, Rosen RJ, Rockman CB, Nalbandian M, Hofstee DJ, Fioole B, et al.
Transcatheter embolization of complex pelvic vascular malformation: results and
long-term follow-up. J Vasc Surg 2001;33:51e5.
3 Lee BB, Bergan JJ. Advanced management of congenital vascular malformations:
a multidisciplinary approach. J Cardiovasc Surg 2002;10:523e33.
4 Ikoma A, Kawai N, Sato M, Tanaka T, Sonomura T, Sahara S, et al. Pathologic
evaluation of damage to bronchial artery, bronchial wall, and pulmonary
parenchyma after bronchial artery embolization with N-butyl cyanoacrylate for
massive hemoptysis. J Vasc Interv Radiol 2011;22:1212e5.
5 Cantasdemir M, Kantarci F, Mihmanli I, Numan F. Embolization of profunda
femoris artery branch pseudoaneurysms with ethylene vinyl alcohol copolymer
(onyx). J Vasc Interv Radiol 2002;13:725e8.

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