Arteriovenous Malformations

of the Foot David Hatch, PGY-2

Madigan Army Medical Center

Case • 34 yo M with RLE swelling/pain

o h/o vein stripping, GSV RFA o Venous duplex LE o MRA o Angiography o Embolization o Continued pain

Case • Continued pain

Angiography • Re-embolization

AV Malformations • Congenital, complex tangle of A/V

o Connected by one or more fistulae

• Brain, lungs, LEs

http://www.mayoclinic.org/diseases-conditions/brain-avm/symptoms-causes/dxc-20129994. Retrieved 06Apr2017. Copyright 1998-2017 Mayo Foundation for Medical Education and Research.

Pathophysiology • Somewhat unknown • Most common congenital

maldevelopment • Also, trauma,

degenerative vascular diseases, and iatrogenic causes

• Subintimal fibrosis and smooth muscle hypertorphy

• No malignant characteristics

http://www.wikiwand.com/en/Arteriovenous_malformation.

Signs/Symptoms • Skin coloration • Pigmented lesion or birthmark • Macules, nodules, verrucous fields, scaling

violaceous plaques • Inflammation • Mass/swelling

http://www.podiatrytoday.com/when-arteriovenous-malformation-arises-foot. Podiatry Today. Volume 29 Issue 2. February 2016. Judd, Tanya M, DPM; Thornberry, Lauren, DPM, LT, MSC, USN NAS.

S/S (cont.) • Pulsations / thrill

o Not usually in foot

• Neuro deficits o d/t compression phenomenon

• Varicosities • Ulcerations • CV

Percutaneous embolization of arteriovenous malformations at the plantar aspect of the foot. Wayne Yakes, MD, Marc Huguenot, MD, Alexis Yakes, Alexander Continenza, MD, Raphael Kammer, MD, and Iris Baumgartner, MD. (J Vasc Surg 2016;64:1478-82.)

Diff dx • Derm symptoms suggest

o Angiodermatitis o Kaposi Sarcoma o AVF o Hemangiomas o Glomus tumor o Angiosarcoma

• Physical symptoms suggest o Neuropathy o PVD or ischemia o Venous HTN o Plantar fasciitis/tarsal tunnel syndrome

http://www.birthmarks.us/vm.htm. Orhan Konez, MD. Retrieved 06 April 2017.

Imaging • X-ray • Venous duplex • CT highly sensitive • MRA

Arteriovenous Malformation: An Unusual Reason for Foot Pain in Children. Posted on December 1, 2009. Kunze, B. , Kluba, T., Ernemann, U., Miller, S. The Foot and Ankle Online Journal 2 (12): 1.

Case • Pain in midfoot • Exam unremarkable • CT/MRI

o Bony erosions

Mohammad HR, Bhatti W, Pillai A. An unusual presentation of arteriovenous malformation as an erosive midfoot lesion. Journal of Surgical Case Reports, 2016;8,1–3.

Imaging • Gold standard for LE

AVMs: digital subtraction angiography

Treatment • Ligation • Surgical excision

o Three arteries in foot

• Amputation

Yu, Gerard V.; Brarens, Robert M.; Vincent, Andrew L. Arteriovenous Malformation of the Foot: A Case Presentation. JFAS, 43(4):252-259, 2004.

Embolization

Vaidya S, Tozer KR, Chen J. An Overview of Embolic Agents. Semin Intervent Radiol 2008;25:204–215.

Embolization • Preferred therapeutic option • ETOH • Coils • Glue (N-Butyl-2 Cyanoacrylate) • Ethylene vinyl alcohol copolymer

(Onyx) • Concern for arterial occlusion

leads to recurrence

Vaidya S, Tozer KR, Chen J. An Overview of Embolic Agents. Semin Intervent Radiol 2008;25:204–215.

Treatment • Conservative? Immobilization • Case Report:

o A Nonsurgical Approach to Arteriovenous Malformation of the Foot: A Case Report. Faith A. Schick, DPM. Journal of the American Podiatric Medical Association, Vol 105 No 4 July/August 2015.

• PF diagnosed initially o MRI revealed AVM

Schick FA. A Nonsurgical Approach to Arteriovenous Malformation of the Foot: A Case Report. Journal of the American Podiatric Medical Association, Vol 105, No 4 July/August 2015.

Treatment • Conservative? Immobilization • Case Report:

o A Nonsurgical Approach to Arteriovenous Malformation of the Foot: A Case Report. Faith A. Schick, DPM. Journal of the American Podiatric Medical Association, Vol 105 No 4 July/August 2015.

• PF diagnosed initially o MRI revealed AVM

• Relief with 6 weeks CAM boot, dispensed CFO

Schick FA. A Nonsurgical Approach to Arteriovenous Malformation of the Foot: A Case Report. Journal of the American Podiatric Medical Association, Vol 105, No 4 July/August 2015.

References 1. Yu, Gerard V.; Brarens, Robert M.; Vincent, Andrew L. Arteriovenous Malformation of the Foot:

A Case Presentation. JFAS, 43(4):252-259, 2004. 2. Waterson KW, Shapiro L, Dannengerg M. Developmental arteriovenous malformation with

secondary angiodermatitis—report of a case. Arch Dermatol 100:297–302, 1969. 3. Kadono T1, Kishi A, Onishi Y, Ohara K. Acquired digital arteriovenous malformation: a report of

six cases. Br J Dermatol. 2000 Feb;142(2):362-5. 4. Schick FA. A Nonsurgical Approach to Arteriovenous Malformation of the Foot: A Case Report.

Journal of the American Podiatric Medical Association, Vol 105, No 4 July/August 2015. 5. Fayad L, Hazirolan T, Bluemke D, et al. Vascular malformations in the extremities: emphasis on

MR imaging features that guide treatment options. Skelet Radiol 35: 127, 2006. 6. Yakes W, Huguenot M, Yakes A, Continenza A, Kammer R, Baumgartner I. Percutaneous

embolization of arteriovenous malformations at the plantar aspect of the foot. J Vasc Surg 2016;64:1478-82.

7. Yakes WF. Yakes’ AVM classification system. Journal of Vascular and Interventional Radiology, 2015-02-01, Volume 26, Issue 2, Pages S224-S224

8. Shin BS, Do YS, Cho HS, Kim DI, Hahm TS, Kim CS, Ko JS, Bang SR, Park KB, Cho SK, Park HS, Kim S. Effects of Repeat Bolus Ethanol Injections on Cardiopulmonary Hemodynamic Changes during Embolotherapy of Arteriovenous Malformations of the Extremities. J Vasc Interv Radiol 2010; 21:81–89.

9. Peters ZJ, Tan K, Simons M. Embolization therapy of high-flow hand and foot arteriovenous malformations: challenges of treatment and lessons learned. JVIR. March 2014, Volume 25, Issue 3, Supplement, Page S53.

10. Vaidya S, Tozer KR, Chen J. An Overview of Embolic Agents. Semin Intervent Radiol 2008;25:204–215.

11. Mohammad HR, Bhatti W, Pillai A. An unusual presentation of arteriovenous malformation as an erosive midfoot lesion. Journal of Surgical Case Reports, 2016;8,1–3.