Review Question - QID 213919

This patient has an arteriovenous malformation (AVM); this is a multidisciplinary problem that may benefit from surgical excision, embolization, or sclerotherapy if other modalities fail to provide relief.

Although consulting another specialty is almost never the correct answer, this question emphasizes the multidisciplinary role of managing patients with an AVM, reinforced by the two accompanying previously tested references. Although rarely symptomatic, these lesions can be very difficult to treat when symptomatic. Non-operative management may consist of compression stockings, activity modification, and aspirin/anticoagulants. Resection can be very morbid or impossible depending on the location. Endovascular techniques include coil embolization and/or sclerotherapy with liquid or foamed sclerosants injected directly into the vasculature.

Pimpalwar et al. describe the management approach for treating congenital vascular malformations from the perspective of an interventional radiologist. They describe staged sclerotherapy and embolization techniques for the management of these problems as alternatives to surgical resection. They stress an adequate understanding of the architecture of these lesions and blood flow in successfully treating these lesions, further supporting a multidisciplinary approach.

Lidsky et al. similarly discuss the multidisciplinary approach to the management of vascular malformations. They provide an algorithm for approaching these lesions that is differentiated by high- and low-flow lesions. They prospectively applied this algorithm to a cohort of 136 malformations in 135 patients and found a high rate of treatment success and limited complications.

Figure A is a clinical photo of a foot with a dorsal AVM. Figure B is an XR demonstrating an overlying, non-specific soft tissue mass. Figures C and D are T1 and STIR MRIs, respectively, demonstrating a well-defined, dorsal, heterogeneous soft tissue mass. The lesion enhances more on STIR, highlighting subacute areas of hemorrhage, stippled fat, and blood vessels.

Illustration A is a general algorithm for the management of vascular malformations (HFVM, high-flow vascular malformation; LFVM, low-flow vascular malformation). Illustration B is an example of multiple phleboliths characteristic of an AVM on x-ray.

Incorrect Answers:
Answer 1: Although AVMs can be associated with several inherited disorders and found in other parts of the body, this condition does not represent a neoplasm with metastatic potential requiring staging.
Answer 2: An AVM can be diagnosed based on physical exam and imaging along; plain films showing phleboliths and an ultrasound showing blood flow are useful in establishing a diagnosis.
Answers 3 and 4: There is no role for "neoadjuvant chemotherapy" or radiation for AVM.