Vascular Malformations Sd

Arteriovenous MalformationDepartment of Otolaryngology Head & Neck SurgeryFaculty of Medicine Universitas PadjadjaranHasan Sadikin General Hospital Bandung2014

DR.ESSAM EL-KADY---FRCS

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.

INTRODUCTIONArteriovenous malformationUsually extratruncularInitially present as local swelling, thrill, bruits, local hyperthermiaDevelop symptoms of shunting skin necrosis, distal gangrene, high output cardiac failureNidus present central area of AV connection (no capillaries)High flow lesionsDevelop dilated, thickened, tortuous vessels, arterialized veins (medial thickening and fibrosis)Most morbidity, highest rate of recurrence

CLASSIFICATION of VASCULAR MALFORMATIONSHemangiomas

Vascular Malformations:Low-flow Vascular MalformationCapillary MalformationVenous MalformationsLymphatic MalformationsLymphatic Venous MalformationsHigh-flow Vascular MalformationAVMs (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.

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

HemangiomaMalformationClinicalUsually absent at birth, 30% present as red maculeAll present at birth; may not be evidentRapid postnatal proliferationCommensurate growth; rapid growth possible with hormonal changes, trauma, or infectionSlow involutionNo involutionFemale:male ratio 3:1Female:male ratio 1:1CellularPlump endothelium, increased turnoverFlat endothelium, slow turnoverIncreased mast cell countNormal mast cell countMultilaminated basement membraneNormal thin basement membraneCapillary tubule formation in vitroPoor endothelial growth in vitro

PATHOLOGYLow-Flow Vascular MalformationsLymphatic 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

PATHOLOGYHigh-flow Vascular MalformationsArteriovenous 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.

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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 limbsLocalized: common in any organ

DIAGNOSISAngio- 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 availabilityUltrasonography 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 AngiographyCT AngiographyMRI Angiographyhttp://www.seslhd.health.nsw.gov.au

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

TREATMENTComplete 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.

THANK YOUDR.ESSAM EL-KADY---FRCS


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 Radiologic Angiographic findings: well-circumscribed, intense lobular-parenchymal staining with equatorial vessels Angiographic findings: diffuse, no parenchyma Low flow: phleboliths ectatic channels High flow: enlarged, tortuous arteries with arteriovenous shunting Magnetic resonance imaging finding: Intermediate signal intensity on T1-weighted images that increases on T2-weighted sequences; flow voids present on both T1- and T2-weighted images Skeletal Infrequent mass effect on adjacent bone; rarely hypertrophy Low flow: distortion, hypertrophy, or hypoplasia High flow: destruction, distortion, or hypertrophyDR.ESSAM EL-KADY---FRCS

Usually absent at birth, 30% present as red maculeAll present at birth; may not be evidentRapid postnatal proliferationCommensurate growth; rapid growth possible with hormonal changes, trauma, or infectionSlow involutionNo involutionFemale:male ratio 3:1Female:male ratio 1:1

Plump endothelium, increased turnoverFlat endothelium, slow turnoverIncreased mast cell countNormal mast cell countMultilaminated basement membraneNormal thin basement membraneCapillary tubule formation in vitroPoor endothelial growth in vitro


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Vascular Malformations Sd