Extracranial arteriovenous malformations (AVMs) can impair a patient’s quality of life and are sometimes even fatal. Symptoms of extracranial AVMs include disfigurement, destruction of tissue, pain, ulceration, bleeding, and high-output heart failure.1 Although embolization may be employed as a minimally invasive treatment,2 for the head and neck lesions, early resection with proper reconstruction results in increased chances of attaining long-term control.1,3,4
On the other hand, dialysis patients undergoing surgery have an increased risk of mortality and complications owing to their fragile systemic condition.5 Nevertheless, highly invasive surgical procedures are sometimes prioritized to attain the best clinical course.
We experienced a case of a rapidly enlarging AVM in the head and neck of a patient on hemodialysis. A 61-year-old man was referred to our hospital with a diagnosis of AVM involving the right temporoauricular and neck (Fig. 1). He noticed a reddish stain 45 years ago, and the lesion suddenly started growing 4 months before the referral. He had a history of end-stage kidney disease due to type 2 diabetes mellitus and he was on hemodialysis for 5 years.
Fig. 1.
Arteriovenous malformation (AVM) of the head and neck. A, preoperative photograph of the AVM involving the right temporoauricular and neck. The lesion showed rapid enlargement. B, preoperative enhanced computed tomography showing a large AVM.
The lesion grew rapidly during the periodic outpatient follow-up, and we decided to perform surgical resection and reconstruction to attain control of the lesion for the possible long-term. Perioperative management was planned with detailed assessments by cardiologists, nephrologists, diabetologist, anesthesiologists, intensivists, and plastic surgeons. Fortunately, preoperative examinations revealed normal cardiopulmonary function. Laboratory tests showed controlled hemoglobin A1c (4.8%), and hemoglobin concentration was 11.8 g/dL. The extent of ablation was determined in reference to enhanced computed tomography and ultrasonography.
Transfixing sutures4 were placed circumferentially around the incisional line, with threads and polyvinyl chloride tubes binding the cutaneous and subcutaneous tissue to temporarily reduce blood inflow. Multiple ligations with durable thread were also placed in Z-shapes over the AVM to decrease the blood flow before the incision. During ablation, overcasting sutures with a substantial thread were properly placed on the edge of the excision side to decrease hemorrhage. In parallel, the free anterolateral thigh flap was raised and transferred to the defect. The operating time was 7 hours and 10 minutes. The total amount of bleeding was 430 mL, and transfusion was not required perioperatively. The patient made an uneventful postoperative recovery and remains free from re-expansion of the lesion in the last 1 year of follow-up. (See figure, Supplemental Digital Content 1, which displays (a) postoperative appearance of the operative site, 1 year after surgical resection and anterolateral thigh flap reconstruction. (b) Postoperative enhanced computed tomography. The patient remains free from re-expansion of the lesion in the 1 year of follow-up. http://links.lww.com/PRSGO/B600.)
To the best of our knowledge, no reports have described the treatment of extracranial AVMs in patients on dialysis. In our case, the lesion showed rapid enlargement and we evaluated the patient's tolerance to undergo an operation. The benefit of surgical excision was considered to outweigh the risks of operative invasion. Surgical excision of the AVM in the head and neck reconstruction and that in the free flap reconstruction were successfully conducted. With a preoperative elaborate assessment, discussion among the multidisciplinary team, and intraoperative contrivance to reduce hemorrhage, surgical excision of an AVM can be an optimal choice of treatment even in patients on dialysis.
PATIENT CONSENT
The patient provided written consent for the use of his image.
Acknowledgment
The study was conducted in accordance with the Declaration of Helsinki.
Supplementary Material
Footnotes
Published online 24 March 2021
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
Disclosure The authors have no financial interest to declare in relation to the content of this article.
References
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