Advertisement

European Journal of Plastic Surgery

, Volume 27, Issue 4, pp 204–209 | Cite as

Surgical management of a high-flow arteriovenous malformation of the upper extremity producing severe hemodynamic impairment

  • E. PolykandriotisEmail author
  • C. Böhner
  • R. Hess
  • U. Kneser
  • H. Seyhan
  • B. Loos
  • A. Bach
  • J. Kopp
  • R. E. Horch
Case Report
  • 44 Downloads

Abstract

Peripheral arteriovenous (AV) malformations may present with a plethora of clinical symptoms such as paradoxical emboli, severe hypertension, nerve palsies or pain syndromes. Hemodynamically compromising lesions of the limbs are rare and involve high-flow AV fistulae with marked arteriovenous shunting. A female patient with a high-flow arteriovenous malformation of the left upper-extremity is presented. Preoperative assessment by magnetic resonance imaging and magnetic resonance angiography together with a color duplex investigation revealed a hemodynamically compromising arteriovenous fistula (shunt volume 30%) involving the entire left forearm and hand. The lesion was managed operatively with a combination of selective ligation and sclerosing of the feeding artery. There was marked clinical improvement postoperatively. Magnetic resonance angiography confirmed a drastic decrease in the number and size of the arteriovenous fistulae. The shunt ratio was diminished to 10%. Although surgical treatment of arteriovenous fistulae is known to have high complication and recurrence rates, thorough preoperative planning and intraoperative monitoring, can supply the prerequisites for a favorable outcome in severe symptomatic cases.

Keywords

Arteriovenous fistula Hemodynamic impairment Shunt Magnetic resonance angiography 

References

  1. 1.
    Bach A, Walgenbach K, Horch R (2000) Hemangiosarcoma of the left hand in a patient with the rare combination of Maffucci’s and Stewart Treves syndrome. Vasa 29:71–73PubMedGoogle Scholar
  2. 2.
    Bachleda P, Zadrazil J, Vyslouzil K, Utikal P (1993) Die Ischämie der oberen Extremität als Komplikation einer AV-Fistel zur Hämodialyse. Acta Univ Palacki Olomuc Fac Med 135:93–94PubMedGoogle Scholar
  3. 3.
    Berger A, Hierner R (eds) (2003) Plastische Chirurgie. Grundlagen, Prinzipien, Techniken. Springer, Berlin Heidelberg New YorkGoogle Scholar
  4. 4.
    Beutel F, Polykandriotis E, Requardt M, Grünert J (2002) MR-Angiographie als postoperatives Beurteilungskriterium nach mikrochirurgischer Gefässanastomose. In: 43. Symposium der Deutschsprachigen Arbeitsgemeinschaft für Handchirurgie, ViennaGoogle Scholar
  5. 5.
    Chan P, Lee C, Lee Y (1992) High output cardiac failure caused by multiple giant cutaneous hemangiomas. Jpn Heart J 33:493–497PubMedGoogle Scholar
  6. 6.
    Clarkson M, Giblin L, Brown A, Little D, Donohoe J (2002) Reversal of pulmonary hypertension after ligation of a brachiocephalic arteriovenous fistula. Am J Kidney Dis 40:E8CrossRefPubMedGoogle Scholar
  7. 7.
    Coursley G, Ivins J, Barker N (1956) Congenital arteriovenous fistulas in the extremities. An analysis of sixty-nine cases. Angiology 7:201PubMedGoogle Scholar
  8. 8.
    Davis R, Lipsig L, Connolly M, Flinn W (1985) Varicose ulcer of the upper extremity. Surgery 98:616–618PubMedGoogle Scholar
  9. 9.
    Dickey K, Pollak J, Meier G, Denny D, White R (1995) Management of large high-flow arteriovenous malformations of the shoulder and upper extremity with transcatheter embolotherapy. J Vasc Interv Radiol 6:765–773Google Scholar
  10. 10.
    Enjolras O, Ciabrini D, Mazoyer E, Laurian C, Herbreteau D (1997) Extensive pure venous malformations in the upper or lower limb: a review of 27 cases. J Am Acad Dermatol 36:219–225PubMedGoogle Scholar
  11. 11.
    Ford EG, Stanley P, Tolo V, Woolley MM (1992) Peripheral congenital arteriovenous fistulae: observe, operate, or obturate? J Pediatr Surg 27:714–719PubMedGoogle Scholar
  12. 12.
    Garmendia G, Miranda N, Borroso S et al. (2001) Regression of infancy hemangiomas with recombinant IFN-alpha 2b. J Interferon Cytokine Res 21:31–38CrossRefPubMedGoogle Scholar
  13. 13.
    Gloviczki P, Stanson AW, Stickler GB et al. (1991) Klippel-Trenaunay syndrome: the risks and benefits of vascular interventions. Surgery 110:469–479PubMedGoogle Scholar
  14. 14.
    Greene GM, Hart MN, Poor MM Jr, Loftus CM (1990) Carcinoma metastatic to cerebellar vascular malformation: case report. Neurosurgery 26:1054–1056; discussion 1056–1057Google Scholar
  15. 15.
    Griffin JM, Vasconez LO, Schatten WE (1978) Congenital arteriovenous malformations of the upper extremity. Plast Reconstr Surg 62:49–58PubMedGoogle Scholar
  16. 16.
    Holman E (1965) Abnormal arteriovenous communications. Great variability of effects with particular reference to delayed development of cardiac failure. Circulation 32:1001–1009PubMedGoogle Scholar
  17. 17.
    Horch R, Kronung G (1988) A new surgical approach to vasodilating therapy in peripheral occlusive vascular disease. Nippon Geka Hokan 57:487–492PubMedGoogle Scholar
  18. 18.
    Horch R, Kronung G (1989) Infektprophylaxe bei Teflonprothesen für den Dialysezugang. Erfahrungen mit einem resorbierbaren Kollagen-Antibiotikum-Verbundsystem. Vasa 18:30–34PubMedGoogle Scholar
  19. 19.
    Hunter W (1757) The history of an aneurysm of the aorta with remarks on the aneurysm in general. In: Medical Observer and Inquirer, vol. 1, pp. 323Google Scholar
  20. 20.
    Hurwitz DJ, Kerber CW (1981) Hemodynamic considerations in the treatment of arteriovenous malformations of the face and scalp. Plast Reconstr Surg 67:421–434PubMedGoogle Scholar
  21. 21.
    Kamiyama K, Endo S, Horie Y, Koshu K, Takaku A (1985) Neurofibromatosis associated with intra- and extracranial aneurysms and extracranial vertebral arteriovenous fistula. No Shinkei Geka 13:875–880PubMedGoogle Scholar
  22. 22.
    Kretschmar O, Ewert P, Yigitbasi M, Zurbrugg H, Hetzer R, Lange P (2002) Huge pulmonary arteriovenous fistula: diagnosis and treatment and an unusual complication of embolization. Respir Care 47:998–1001PubMedGoogle Scholar
  23. 23.
    Lantin F, Liefrig A (1967) Fistule arterioveineuse du membre superieur. Acta Chir Belg 66:321–328PubMedGoogle Scholar
  24. 24.
    Mendel T, Louis DS (1997) Major vascular malformations of the upper extremity: long-term observation. J Hand Surg [Am] 22:302–306Google Scholar
  25. 25.
    Mulliken JB, Murray JE, Castaneda AR, Kaban LB (1978) Management of a vascular malformation of the face using total circulatory arrest. Surg Gynecol Obstet 146:168–172PubMedGoogle Scholar
  26. 26.
    Naidich JJ, Rofsky NM, Rosen R, Karp N (2001) Arteriovenous malformation in a patient with Bannayan-Zonana syndrome. Clin Imaging 25:130–132CrossRefPubMedGoogle Scholar
  27. 27.
    Rak K, Yakes W, Ray R et al. (1992) MR imaging of symptomatic peripheral vascular malformations. AJR Am J Roentgenol 159:107–112PubMedGoogle Scholar
  28. 28.
    Reid M (1925) Studies on abnormal arteriovenous communications acquired and congenital. I Report of a series of cases. Arch Surg 10:601–638Google Scholar
  29. 29.
    Rutherford R, Anderson B (1990) Diagnosis of congenital vascular malformations of the extremities: new perspectives. Int Angiol 9:162–167PubMedGoogle Scholar
  30. 30.
    Upton J, Coombs CJ, Mulliken JB, Burrows PE, Pap S (1999) Vascular malformations of the upper limb: a review of 270 patients. J Hand Surg [Am] 24:1019–1035Google Scholar
  31. 31.
    Vercellio G, Lorenzi G, Losa S, Agrifoglio G (1985) Treatment of peripheral congenital arterio-venous fistulas. J Cardiovasc Surg (Torino) 26:168–170Google Scholar
  32. 32.
    Von Hippel E (1904) Über eine sehr seltene Erkrankung der Netzhaut. Klinische beobachtungen. Universitäts-Augenklinik, HeidelbergGoogle Scholar
  33. 33.
    Vossmann H, Bertling J (1977) Zur Problematik der arteriovenosen Fisteln. Handchirurgie 9:231–234PubMedGoogle Scholar
  34. 34.
    Walgenbach KJ, Voigt M, Andree C, Stark GB, Horch RE (2001) Management of lypovascularized wounds not responding to conventional therapy by means of free muscle transplantation. Vasa 30:206–211PubMedGoogle Scholar
  35. 35.
    White R, Pollak J, Persing J, Henderson K, Thomson J, Burdge C (2000) Long-term outcome of embolotherapy and surgery for high-flow extremity arteriovenous malformations. J Vasc Interv Radiol 11:1285–1295PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • E. Polykandriotis
    • 1
    Email author
  • C. Böhner
    • 2
  • R. Hess
    • 3
  • U. Kneser
    • 1
  • H. Seyhan
    • 1
  • B. Loos
    • 1
  • A. Bach
    • 1
  • J. Kopp
    • 1
  • R. E. Horch
    • 1
  1. 1.Department of Plastic and Hand SurgeryUniversity of ErlangenErlangenGermany
  2. 2.Department of Diagnostic RadiologyFriedrich-Alexander-UniversityErlangenGermany
  3. 3.Department of Cardiology Internal Medicine IIFriedrich-Alexander-UniversityErlangenGermany

Personalised recommendations