Peripheral high-flow arteriovenous vascular malformations: a single-center experience

To assess the long-term outcomes of patients with high-flow arteriovenous malformations (HFAVMs) of the extremities.

A retrospective review was performed to identify patients with HFAVMs referred for possible intervention between 1988 and 2003. Sixteen patients with upper-limb HFAVMs and 15 patients with lower-limb HFAVMs were identified (18 men, 13 women; mean age, 36.8 years; range, 21.1-72.2 years). Arteriography, duplex imaging studies, or magnetic resonance imaging were performed in all patients.

Follow-up was completed in 30 patients (mean duration, 3.3 years; range, 0.2-13 years), with one patient lost to follow-up. Nineteen had symptoms that warranted endovascular treatment: 13 underwent embolotherapy and six were considered unsuitable because of challenging anatomy that rendered embolization unsafe or impossible. Eleven patients' symptomatology did not warrant treatment and these patients were treated conservatively. The 13 patients treated with embolotherapy underwent a total of 27 treatment sessions (mean, 2.1 sessions per patient; range, 1-5). N-butyl cyanoacrylate and polyvinyl alcohol were used as the embolic agent in 11 and two patients, respectively. Three patients had complete resolution of HFAVM clinically and angiographically, and five patients' symptoms were controlled despite persistence of the HFAVM angiographically. Five patients had no improvement after treatment. Two major complications occurred (7.4% per session or 15.4% per patient): one patient developed a tibial plateau compression fracture and one patient had temporary L5 neuropathy after embolization of the pelvis and thigh. Of the six patients who were considered unsuitable for embolotherapy, one patient died of hepatocellular carcinoma, two had significant progression of symptoms, and the remaining three patients' symptomatology was unchanged. Only one of the nine patients with mild symptoms at presentation had symptom progression during follow-up.

Peripheral HFAVM is a rare and therapeutically challenging condition. Patients with minimal symptoms at presentation do well with conservative treatment, and symptomatic progression is infrequent. Only patients with significant symptomatology should undergo embolization therapy, which invariably requires multiple sessions and must be aimed at eradication of the nidus.