Clinical study
Extremity Arteriovenous Malformations Involving the Bone: Therapeutic Outcomes of Ethanol Embolotherapy

https://doi.org/10.1016/j.jvir.2010.01.035Get rights and content

Purpose

To assess retrospectively the therapeutic results, complications, and therapeutic approach to ethanol embolotherapy of extremity arteriovenous malformations (AVMs) involving the bone.

Materials and Methods

From December 1996 to May 2009, 22 patients (12 male, 10 female; eight children, 14 adults; age range, 1–64 years) with extremity AVMs involving the bone underwent staged ethanol embolotherapy (range, 1–12 procedures; mean, 4.4 procedures) under general anesthesia. Four patients had pure bone AVMs and 18 had mixed bone and soft-tissue AVMs. Pulmonary artery pressure and arterial blood pressure were monitored as ethanol was injected. Ethanol embolotherapy was performed by direct puncture and/or transcatheter approach. Therapeutic outcomes were established by evaluation of the clinical response of symptoms and signs, as well as the degree of devascularization at follow-up angiography or computed tomography.

Results

Ninety-six ethanol embolotherapy procedures were performed in 22 patients. Four (18%) were cured, 14 (64%) showed improvement, three (14%) showed no change, and one (4%) experienced treatment failure and amputation of the affected extremity. Ethanol embolotherapy was considered effective (ie, combined cure and improvement outcomes) in 18 patients (82%). Ten patients (45%) experienced complications. Twelve minor complications (skin and transient peripheral nerve injury; 13%) and one major complications (longstanding nerve palsy; 1%) occurred in 96 procedures.

Conclusions

Ethanol embolotherapy of extremity AVMs involving the bone has the potential to eliminate or improve symptoms in a high percentage of patients, with an acceptable risk of minor and major complications.

Section snippets

Patients

Approval from the institutional review board of our hospital was obtained for a retrospective review of patient medical records, but informed consent was not required. Written consent for the procedures was obtained from all patients.

From December 1996 to May 2009, 125 patients with AVMs in the extremities were referred to our vascular malformation clinic. AVMs with severe overlying skin ulceration and infection and AVMs in a nonfunctioning extremity were contraindications to ethanol

Results

In 125 patients with extremity AVMs, 22 patients (17.6%) had bony involvement of AVMs in the extremities. There was multiple bone involvement in eight patients (36%). During the 96 ethanol embolotherapy procedures performed (range, 1–12; mean, 4.4), the amount of ethanol used ranged from 4 mL to 65 mL and the total dose did not exceed 1 mL/kg body weight in a single session.

Discussion

Primary bone AVMs account for fewer than 1% of all primary intraosseous lesions (21, 22). The incidence and clinical manifestations of extremity AVMs involving the bone are not well known. In the present study, 17.6% of extremity AVMs (22 of 125) had bony involvement, with multiple bone involvement in eight patients (36%). The most common clinical symptom or sign was pain (68%), followed by mass effect with pulsatility (41%), swelling of the extremity (23%), bone overgrowth of more than 2 cm

Acknowledgments

The authors thank Wayne F. Yakes, MD, for his invaluable technical assistance.

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    None of the authors have identified a conflict of interest.

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