Surgery for Congenital Arterial and Venous Anomalies Treatment & Management

  • Author: Jeff L Myers, MD, PhD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Oct 13, 2010
 

Medical Therapy

Hemangiomas

For symptomatic hemangiomas that require intervention (approximately 10% of all cases), topical, intralesional, or systemic corticosteroids are the first line of therapy. If corticosteroid therapy fails, second-line pharmacotherapy with vincristine and interferon-alpha may be attempted. Second-line therapy may also be used first if corticosteroids are contraindicated for other reasons (eg, patient preference). At present, pulsed dye laser therapy is indicated for ulcerating lesions and persistent telangiectasias.[5]

Venous malformations

The initial treatment of venous malformations consists of elastic compression aids to reduce swelling and pain. Daily aspirin may also be administered to prevent thrombotic complications. Sclerotherapy (most often with ethanol) is the mainstay of treatment and may be performed for lesions refractory to the above measures. Sclerotherapy should be performed under general anesthesia, with radiographic (ultrasonographic/fluoroscopic) guidance. With repeated therapy, the success rate of improvement in function and reduction in symptoms can reach 76%.[35]

Capillary malformations

Cosmetic camouflage and laser photocoagulation are the current first-line treatments for capillary malformations.[5] Flashlamp pulsed dye lasers are most often used, although the results of such therapy are mixed. Multiple treatments are usually required, and nearly half of all lesions will darken within 5 years of treatment.[36]

Lymphatic malformations

Macrocytic lesions may be effectively treated with sclerotherapy. Both bleomycin and OK-432 (attenuated group A Streptococcus pyogens) have been shown to be effective as intralesional sclerotic agents for lymphatic malformations.[37, 38] A 2008 series by Burrows et al has also evaluated the use of doxycycline as an effective sclerosing agent for lymphatic malformations.[39] Carbon dioxide, argon, and YAG laser therapy can also be used to treat mucosal lesions, although malformations treated with this therapy often recur, requiring repeat treatment.

Arteriovenous malformations

Medical therapy has little role in the management of arteriovenous malformations (AVMs).

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Surgical Therapy

Hemangiomas

Early tracheostomy may be warranted for lesions that threaten the airway.

Surgical resection may be appropriate for lesions that are refractory to medical management and that continue to present problems such as ulceration. Resection may be performed at any of the 3 stages of the life cycle. In general, resection should be deferred until the involuted phase (late childhood), when the lesion has matured and the anesthetic risk to the child is decreased. However, specific indications have been suggested for resection at all phases, as summarized by Marler and Mulliken:[5]

  • Infancy (proliferative phase): Indications for resection include obstruction (visual or subglottic), deformity (eg, periorbital distortion), bleeding, ulceration, involvement of the scalp (to prevent alopecia of the effected region), and anticipation of a scar caused naturally by the lesion that would be more marked than that caused by surgical intervention.
  • Early childhood (involuting phase): Large protuberant lesions are resected in this phase, as children of this age generally become aware of physical appearance. Excision may be performed at this point if resection is considered inevitable, the resultant scar is similar to that achieved by waiting to excise in the involuted phase, and the scar may be easily hidden.
  • Late childhood (involuted phase): Indications for resection in this phase include damaged skin, abnormal contour, and distortion of skin or surrounding structures.

Optimal timing and technique of surgical excision should be tailored on a case-by-case basis, since no two lesions or patients are alike.

Venous malformations

Sclerotherapy is the primary interventional treatment for venous malformations; however, surgical excision may be offered for selected lesions. Small localized lesions are the best candidates for surgical intervention. In general, sclerotherapy should be used to shrink lesions prior to surgical excision.

Capillary malformations

Small fibrovascular lesions can easily be excised in most locations. More extensive excision and grafting of select capillary malformations may also be performed. Facial lesions with concomitant disfigurement may require excision with full- or split-thickness grafts accompanied by contour resection and correction of maxillofacial distortion.[40, 41]

Lymphatic malformations

Surgical resection is the mainstay treatment for lymphatic malformations. In general, resection should be deferred until late infancy or early childhood to minimize anesthetic risk and to allow for easier dissection of neurovascular structures often associated with complex lesions. Often, lymphatic malformations encompass vital structures, precluding complete excision. Stages approached are often used. The approach to resection varies with lesion location. Generally, total excision of the lesion is attempted, with careful identification and preservation of involved major nerves (eg, preservation of the brachial plexus when excising an axillary lesion).

Resections tend to be involved, and wound complications such as infection, drainage, swelling, and seroma formation are common.

Arteriovenous malformations

Treatment of AMVs consists of a combination of embolization, sclerotherapy, and surgical resection. Angiography is a required for intervention, as it delineates the extent of the lesion and clearly outlines the feeding and draining vessels. Surgical ligation of feeding vessels should not be performed, as this prevents further access for angiography and only induces recruitment of new vessels into the lesion.[5]

Embolization may be performed with coils, particles, or glue via a venous or arterial approach. Sclerotherapy may be delivered in the nidus of the lesion with concomitant occlusion of feeding and draining vessels. Various sclerosing agents, such as absolute ethanol and N-butyl cyanoacrylate (NBCA) have been described.[42] Combinations of embolization and sclerotherapy may be used to treat lesions that may not be amenable to surgical resection, although these measures provide temporary improvement, as new vessels are readily recruited into the lesion.

If a lesion is deemed appropriate for surgical excision, preoperative embolization therapy is usually recommended to aid in resection. Select lesions (eg, small malformations on the extremities) may be excised without preoperative embolization. Operative intervention is indicated to facilitate complete excision and to minimize recurrence (staged procedures are usually not performed). Excision should include the nidus of the lesion, as well as any involved skin or deeper tissues. Wide excision is often necessary, with the extent of the resection based on delineation of the lesion by preoperative imaging, bleeding patterns at the resection margin (ie, consistent with normal dermal vasculature or extensive bleeding indicative of the malformation), and frozen sections of the resection margin. Large excisions may necessitate grafting or tissue transfer for adequate wound closure.

Deep intracranial and complex craniofacial AVMs present a unique therapeutic challenge, as surgical excision is often impossible. Embolization is the usual treatment modality for such lesions, and radiotherapy has been successfully used to treat such intracranial lesions.[43]

Combined malformations

Surgical treatment should be specifically tailored for these lesions. Usually, surgical intervention is reserved for correcting orthopedic disfigurement of the extremities or improving functionality of limbs and digits.

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Preoperative Details

See Surgical Therapy.

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Intraoperative Details

See Surgical Therapy.

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Postoperative Details

See Surgical Therapy.

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Follow-up

In general, vascular anomalies comprise a chronic and complex group of lesions that require long-term follow-up and care. While no treatments can be said to be curative for all problematic lesions, most malformations can be treated to achieve mitigation of symptoms if the correct diagnosis is made early and the proper interventions implemented. Patients should be observed in multidisciplinary clinics, if appropriate, and consultation with a surgeon should be sought early.

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Complications

Complications of therapy depend on the nature of the lesion and type of intervention used.

Systemic corticosteroid therapy used to treat hemangiomas may produce the expected complications of such therapy (eg, gastric irritation, temporary growth retardation, cushingoid appearance). Local intralesional administration may be complicated by damage to surrounding structures such as the eye.[44]

In general, treatment of malformations with sclerotherapy may result in local complications, including nerve injury, cutaneous necrosis, blistering, and injury to surrounding structures.[35]

Laser or phototherapy often fails to permanently resolve lesions, with high rates of recurrence.

Short-term complications of surgical excision may include bleeding and infection. Protracted wound problems may also occur, depending on the nature of the lesion. Edema, pain, seromas, and prolonged drainage may occur at resection sites. Functional loss (of limbs and hands) and need for repeat excisions (as with lymphatic malformations) may also be potential complications of surgical management.

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Outcome and Prognosis

Most hemangiomas have a self-limited course, leaving only a mild blemish or nearly imperceptible skin changes at the lesion site. However, the outcome of lesions that require intervention or operative management is heavily influenced by the nature and site of the lesion. For example, facial lesions may result in long-term cosmetic disfigurement.

Most vascular malformations represent progressive lesions, and long-term outcomes vary depending on the nature, size, and location of a specific lesion. Lesions such as AVMs and small vascular malformations are more likely to be "cured" with surgical measures, as opposed to lymphatic malformations and mixed lesions. However, all of these lesions require long-term follow-up and vigilance to determine the efficacy of therapeutic intervention.

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Future and Controversies

Vascular anomalies require further study to elucidate the underlying mechanisms by which they occur and evolve. Presently, therapy is largely geared toward treatment of the sequelae of lesions, and, often, a single therapy is not enough. As our understanding of these complex entities improves, therapy might be guided toward early prevention of vascular lesions and more definitive therapies.

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Contributor Information and Disclosures
Author

Jeff L Myers, MD, PhD  Chief, Pediatric and Congenital Cardiac Surgery, Department of Surgery, Massachusetts General Hospital; Associate Professor of Surgery, Harvard Medical School

Jeff L Myers, MD, PhD is a member of the following medical societies: American College of Surgeons, American Heart Association, and International Society for Heart and Lung Transplantation

Disclosure: Nothing to disclose.

Coauthor(s)

Ahmad Y Sheikh, MD  Resident Physician, Department of General Surgery, Massachusetts General Hospital

Ahmad Y Sheikh, MD is a member of the following medical societies: American College of Surgeons and American Heart Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeff L Myers, MD, PhD  Chief, Pediatric and Congenital Cardiac Surgery, Department of Surgery, Massachusetts General Hospital; Associate Professor of Surgery, Harvard Medical School

Jeff L Myers, MD, PhD is a member of the following medical societies: American College of Surgeons, American Heart Association, and International Society for Heart and Lung Transplantation

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jonah Odim, MD, PhD, MBA  Senior Medical Officer, Transplantation Immunology Branch, Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health

Jonah Odim, MD, PhD, MBA is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physician Executives, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, Association for Academic Surgery, Association for Surgical Education, Canadian Cardiovascular Society, International Society for Heart and Lung Transplantation, National Medical Association, New York Academy of Sciences, Royal College of Physicians and Surgeons of Canada, Society of Critical Care Medicine, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

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