Arteriovenous Malformation

Department of Otolaryngology
Head & Neck Surgery
Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin General Hospital Bandung
2014

INTRODUCTION
Arteriovenous malformations (AVMs)
congenital lesions composed of a complex tangle of
arteries and veins connected by one or more fistulae.

AVM at external ear second most common site for extracranial

arteriovenous malformation in the head and neck.

Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a
multidisciplinary approach. J Vasc Surg. 2004;39:590600.

INTRODUCTION

Arteriovenous malformation

Usually extratruncular
Initially present as local swelling, thrill, bruits, local hyperthermia
Develop symptoms of shunting skin necrosis, distal gangrene,
high output cardiac failure
Nidus present central area of AV connection (no capillaries)
High flow lesions
Develop dilated, thickened, tortuous vessels, arterialized veins
(medial thickening and fibrosis)
Most morbidity, highest rate of recurrence

CLASSIFICATION of VASCULAR
MALFORMATIONS

Hemangiomas

Vascular Malformations:

Low-flow Vascular Malformation

Capillary Malformation
Venous Malformations
Lymphatic Malformations
Lymphatic Venous Malformations

High-flow Vascular Malformation

AVMs (arteriovenous malformations)
Artery Malformation

Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a
multidisciplinary approach. J Vasc Surg. 2004;39:590600.

Epidemiology

Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a
multidisciplinary approach. J Vasc Surg. 2004;39:590600.

Hemangioma

Malformation

Clinical
Usually absent at birth, 30% present
as red macule

All present at birth; may not be

evident

Rapid postnatal proliferation

Commensurate growth; rapid

growth possible with hormonal
changes, trauma, or infection

Slow involution

No involution

Female:male ratio 3:1

Female:male ratio 1:1

Cellular
Plump endothelium, increased
turnover

Flat endothelium, slow turnover

Increased mast cell count

Normal mast cell count

Multilaminated basement membrane

Normal thin basement membrane

Capillary tubule formation in vitro

Poor endothelial growth in vitro

PATHOLOGY

Low-Flow Vascular Malformations

Lymphatic malformations Micro cystic lymphatic

malformations consist of mass like soft-tissue abnormalities.

Lymphatic venous malformations a combination of

abnormal lymphatic and venous channels.
Capillary malformations (port-wine stains) common
birthmarks and involve only the superficial tissues (skin)
Venous malformations spongy, masslike lesions
composed of abnormal veins, ie, veins with a relative lack of
smooth muscle cells in their walls

PATHOLOGY

High-flow Vascular Malformations

Arteriovenous

malformations considered to be
congenital vascular anomalies,
but are usually first noted several years after birth or after
certain triggering changes such as trauma or the hormonal
changes of puberty or pregnancy.

http://www.politedissent.com/archives/1331

There are four recognized stages of AVMs:

Stage I lesion has a pinkish-bluish stain and warmth.

Stage II, the lesion has pulsations, thrill, and bruit.
Stage III, the patient has dystrophic skin changes,
ulceration, bleeding, and pain.
Stage IV, the patient has high-output cardiac failure.

There are three major groups of AVMs:

Truncal: common in the head, neck, upper limb and lower

limb and pelvis (trunk area).
Diffuse: common in the lower limbs
Localized: common in any organ

DIAGNOSIS
Angio- MRA- CT angio:

The gold standard for high-flow anomalies is conventional

arteriography,
The new noninvasive angiographic techniques such as magnetic
resonance angiography (MRA) or computed tomographic
angiography (CT-angio) offer noninvasive assessment of the flow
dynamics and vasculature of high-flow anomalies (eg,
arteriovenous malformation, arteriovenous fistula).

Duplex ultrasonography:

Good portability and availability

Ultrasonography quickly evaluate anomalies during the
patient's initial visit. It is also used to triage patients and
schedule them for appropriate treatment.

MRI

Is the imaging study of choice

Conventional
Angiography

MRI
Angiography

http://www.seslhd.health.nsw.gov.au

CT
Angiography

Treatment for AVMs

Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a
multidisciplinary approach. J Vasc Surg. 2004;39:590600.

TREATMENT

Complete surgical excision is the only way to ensure a permanent,

successful treatment (stage I malformation is possible)
Embolization: It has been the only feasible treatment option for most
arteriovenous malformations. Embolization, which closes off the
arterial feeders of the malformation, is generally effective in
arteriovenous malformations to stabilize the malformation.
Combined treatments
serial embolization followed by surgical resection, or
embolization followed by sclerotherapy.

Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a
multidisciplinary approach. J Vasc Surg. 2004;39:590600.

DR.ESSAM EL-KADY---FRCS

THANK YOU

DR.ESSAM EL-KADY---FRCS

DR.ESSAM EL-KADY---FRCS

Usually absent at birth, 30% All present at birth; may not

present as red macule
be evident

Rapid postnatal proliferation Commensurate growth;

Hemangioma Malformation Clinical Usually absent
birth, 30%
present aswith
red macule All
rapid atgrowth
possible
present at birth; may not be evident Rapid postnatal proliferation Commensurate growth; rapid
hormonal
trauma,
growth possible with hormonal changes, trauma,
or infection changes,
Slow involution
No involution
Female:male ratio 3:1 Female:male ratio 1:1 or
Cellular
Plump endothelium, increased turnover
infection

Flat endothelium, slow turnover Increased mast cell count Normal mast cell count
Multilaminated basement membrane Normal thin basement membrane Capillary tubule
Slowin involution
No
involution
formation
vitro Poor endothelial growth in vitro
Radiologic
Angiographic findings: wellcircumscribed, intense lobular-parenchymal staining with equatorial vessels Angiographic findings:
diffuse,
no parenchyma ratio 3:1
Female:male
Female:male ratio 1:1
Low flow: phleboliths ectatic channels
High flow: enlarged, tortuous arteries with arteriovenous shunting Magnetic resonance imaging
finding:
Intermediate signal intensity on
Plump
endothelium,
T1-weighted
images that increases on Flat endothelium, slow
T2-weighted sequences;
on both T1- and T2-weighted images Skeletal
increased
turnover flow voids present
turnover
Infrequent mass effect on adjacent bone; rarely hypertrophy Low flow: distortion, hypertrophy, or
hypoplasia
mast
cell count
Normal mast cell count
HighIncreased
flow: destruction,
distortion,
or hypertrophy

Multilaminated basement
membrane

Normal thin basement

membrane DR.ESSAM EL-KADY---FRCS