SLR - April 2014 - Satwinder Kaur Gosal
Reference: Hyun D, Do YS, Park KB, Kim DI, Kim YW, Park HS, Shin SW, Song YG; Ethanol Embolotherapy of Foot Arteriovenous Malformations. Journal of Vascular Surgery. 2013 Dec;58(6):1619-26
Scientific Literature Review
Reviewed By: Satwinder Kaur Gosal, DPM
Residency Program: Massachusetts General Hospital, Boston, MA
Podiatric Relevance: Arteriovenous malformations (AVMs) are vascular anomalies which shunt high-velocity and low-resistance flow from the arterial vasculature into the venous systems through fistular communications. AVMs of the foot may compromise a patient’s quality of life and ambulatory function. Treatment options include surgical removal, feeding artery ligation, and other interventional treatments, including embolization techniques.
Methods: A total of 33 patients with foot AVMs were seen at a vascular malformation clinic from 1997-2012. Prior to treatment, electronic medical records were reviewed, focusing on clinical manifestation, history, pulmonary artery pressure along with related minor and major complications. The most common presenting symptom was pain, followed by ulcer, varicosities and swelling. Patients were classified into two groups: pulsating mass and ulcer. Twenty-nine of the patients were treated by ethanol embolization - either transarterial or via direct puncture. Two radiologists analyzed the extent of AVM involvement, angiographic type classification, presence of feeding artery aneurysm, degree of devascularization after treatment, and final results. Statistical analysis consisted of Mann-Whitney test and Spearman correlations.
Results: Presenting symptoms were markedly improved in 19 patients. Six patients showed partial improvement and four patients were unchanged. On baseline angiogram, 62 percent (18/29) involved less than 25 percent of the foot, 24 percent (7/29) involved 25 percent - 33 percent of the foot, 10 percent (3/29) involved more than 66 percent of the foot, and 3 percent (1/29) involved 33 percent - 50 percent of the foot. Most common modified angiographic type was type IIIa (38 percent), followed by IIIb (31 percent), II (14 percent), IIIa + IIIb (7 percent), and II + IIIa (3 percent). None of the foot AVMs demonstrated involvement distal to metatarsophalangeal joints. A total of 61 ethanol embolizations were performed. Seventeen patients underwent one embolization, 10 underwent 2-5, and two underwent more than five. Cure was achieved in seven patients (24 percent), seventeen patients (59 percent) experienced partial resolution, and three patients (10 percent) showed no change. Treatment failure was documented in two patients (7 percent). For correlation analysis between lesion extent and outcome, lesions were re-classified post-treatment into two groups: foot involvement <25 percent and foot involvement >25 percent. Lesions less than 25 percent had a 100 percent success rate, while those greater than 25 percent had a 55 percent success rate. Lesion extent had a moderate correlation with outcome (P<.001, p=0.633). Angiographic types were grouped into three types: II, IIIa, and IIIb, in correlation analysis between angiographic type and outcome. There was no correlation between angiographic type and outcome. (P>0.5, p= 0.143). Minor complications occurred in 52 percent while major complications occurred in 24 percent.
Conclusion: This is the first and largest study to analyze AVMs involving the foot. Ethanol embolization therapy can be a safe and effective treatment. Angiographic findings suggest that lesions <25 percent foot involvement resulted in better treatment outcomes.