Long-term outcome of embolotherapy and surgery for high-flow extremity arteriovenous malformations

PURPOSE: To assess the long-term efficacy of embolotherapy in combination with surgery for management of symptomatic high-flow arteriovenous malformations (HFAVMs) of the lower and upper extremities. MATERIALS AND METHODS: Twenty consecutive patients with symptomatic high-flow lower extremity AVMs (LE-AVMs; n = 9) and upper extremity AVMs (UE-AVMs; n = 11) were treated from 1982 to 1999. All nine patients with LE-AVM had pain and seven had ulceration of the skin. All 11 patients with UE-AVM had debilitating pain, seven had weakness of the affected hand, and two had bony erosion. Embolization of the nidus beneath the site of maximum pain or ulceration was performed percutaneously from the femoral artery through coaxially placed microcatheters (n = 18) or surgical cutdown (n = 2), Cyanoacrylate (isobutyl or n-butyl) diluted with iophendylate or ethiodized oil was used in 19 of 20 patients, RESULTS: Follow-up was completed in eight of nine patients with LE-AVM (mean, 8.6 y) and nine of 11 patients with UE-AVM (mean, 7.4 y) after treatment. One patient with localized LE-AVM was functioning well 13 years after embolotherapy and another was functioning well 16 years after undergoing three embolotherapy procedures and two skin grafts. Five of nine patients with LE-AVM required below-the-knee (n = 4) or above-the-knee (n = 1) amputation 1-6 years after technically and clinically successful embolotherapy. All three trifurcation arteries were diffusely involved in HFAVM in patients requiring amputation. Healing of the two amputation sites, involved by AVM at the knee, was excellent after preoperative geniculate artery embolotherapy. All 11 patients with UE-AVM experienced marked symptomatic improvement; seven after embolotherapy alone and the other four after resection of AVM, One complication of digital spasm was reversed by administration of nerve blocks. CONCLUSIONS: LE-AVM with diffuse involvement of all three trifurcation arteries ultimately required amputation because of recurrence of symptoms after technically and clinically successful embolotherapy. Cyanoacrylate embolotherapy alone or in combination with surgical resection of the AVM provided excellent longterm palliation in patients with UE-AVM.