Dr. Ahmed Mirza Al-Shammasi2031040009

Surgical Intern - KFU – Saudi Arabia

Arteriovenous Malformations

OutlinesDefinitionClassificationEpidemiologyPathophysiologyClinical PresentationDiagnosisManagement

Arteriovenous Malformations

Congenital Vascular anomaly in which there is abnormal connection between the arterial and venous systems.

Malformed vessel that results from developmental arrest during embryogenesis.

Vascular Anomalies

One of the most confusing and misunderstood conditions.

History of inconsistent terminology:Strawberry NevusCherry HemangiomaPort-wine stain

Confusion between Vascular malformations and Vascular tumors of childhood.

International Society for Vascular Anomalies in 1996

VascularAnomalies

Vascular Tumors of Childhood

Vascular Malformation

sCapillary

Hemangioma

Cavernous Hemangioma

Mixed Hemangioma

Venous

Arteriovenous

Arterial

Combined, Mixed

Lymphatic

Epidemiology

Records from the Heim Pal Hospital for Children in Budapest indicated an incidence of 1.2%.

Both sexes are affected equally.No racial predilection has been identified.Venous Malformation is the most common (50%)Followed by AVM, then Combined, lastly Arterial.AVM is more common in the intracranial

vasculature, most dangerous type.

Pathophysiology

Arrest in the development of the primitive vascular system.

Depending on the stage of arrest, divided into: Truncular and Extratruncular.

Arteries have deficient Mascularis layers, veins are dilated due to high flow.

The exact underlying eitiology is unknown

Clinical Presentation

Present as:Mass lesionBirthmarksAtypical varicositiesLimb enlargement

Most are evident at birth, except AVM which present at early childhood or adolescence.

Venous Malformations

Most common type, 50%.Pure venous or mixed.Diffused, soft, non-pulsatile,

compressible mass, bluish hue.Rapid refilling after release of pressure.Tend to enlarge over time, darkening and

superficial thickeningComplications: Thrombophlebitis,

Infection.

Arteriovenous Malformations

Cluster of AVFs that remained from early embryonic development.

Account for 1/3 of cases of VA.Potentially the most serious type.More common intracranially.Present commonly in later childhood,

adolescence or early adulthood.Complications: Steal syndrome (Ischemia,

Pain, Ulceration), Bleeding.

Staging of AVMsStage Manifestation

Stag IQuiescence

Cutaneous blush or warmth

Stage IIExpansion

Bruit, thrill or other signs of expansion

Stage IIIDestruction

Pain, bleeding, ulceration or infection

Stage IVDecompensati

onCardiac Failure

Arterial MalformationsLeast common type, 1-2% of total.Under-development of an arterial segment.Blood flows normally through an

undeveloped side channel or collateral.Enlarging bypassing segment is vulnerable

to:Compression/InjuryAneurysmal dilatationClot formation/obstruction

Ex. Persistent Sciatic Artery

DiagnosisEssentially by Imaging studies:

US (initial evaluation)CT scan, CT AngiographyMRI, MRA (leading imaging modality)Conventional Angiography

1.Diagnosis2.Determine the extent of the lesion3.Search for associated abnormalities

ManagementVenous Malformations:

Compressive stockings ± AspirinSclerotherapy, LASER surgery, Resection

Arteriovenous Malforamtions:Conservative treatment in absence of

symptomsSuper-selective embolization followed by

sclerotherapySelective embolization followed by surgical

resection

Management

Lymphatic MalformationsCompressive stockings are the

mainstay of ttt.Soft tissue debulking.LASER Surgery, Surgical resection

ReferencesRutherford Vascular Surgery, 6th edition.Terminology and classification of congenital

vascular malformations. Phlebology 2007; 22: 249–252

Evaluation and Treatment of Musculoskeletal Vascular Anomalies in Children: An Update and Summary for Orthopaedic Surgeons. UPOJ 2001; 14: 15-24

Arteriovenous Malformations. H Christian Schumacher, MD

Internet:www.emedicine.comwww.vdf.org

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