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Management of Large Vascular Malformation: An Institutional Review

Janarthanan R, Kishore P, Subramania Iyer, Mohit Sharma, Jimmy Mathew.

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Background: Large vascular malformations (VM) are complex lesions anatomically, functionally, or both. The criteria to define “large” vascular malformations were unclear. This study aims to retrospectively identify large VMs based on clinical features and discusses the method we adopted.
Methods: This is a retrospective study of all patients of vascular malformations treated by us since 2003. The criteria to categorize large vascular malformations were outlined after analyzing the anatomical area of involvement, functional disturbances caused by these lesions, operability of the lesions, morbidity associated with resection, and the requirement of reconstruction. All cases were managed by a multi-disciplinary team. Various methods utilized to control the bleeding varied from simple wound packing to cardiopulmonary bypass (CPB) assistance. The resection was either curative or palliative. Complete excision in the form of radical resection was carried out in all possible cases intended with curative aim. Vascularized tissue transfer was done to reduce the morbidity following surgical resection.
Results: Out of 268 patients, 26 fulfilled the criteria for large vascular malformations. The predominant site of involvement is the head and neck. 80% had more than one indication for surgery. The majority of the cases (54%) were arterio-venous malformations (AVM), followed by 31% of capillary venous malformations (CVM). The commonest indication for surgery is bleeding (73%), followed by cosmetic disfigurement (61.5%). Compressive wound packing with delayed wound closure and preoperative embolization were the most commonly employed methods for bleeding control. CPB assisted resection was carried out in 5 cases. On analysing the recurrence, 7.7% had a complete excision, 36% had an incomplete excision, and 12% had cases of vascularized tissue transfer.
Conclusion: The clinical criteria outlined in our study will be useful in identifying “large” vascular malformations. Compression wound packing with delayed closure plays a major role in bleeding control immediately after resection. CPB assistance for aiding resection can be considered in selected cases. A complete resection in the form of a radical excision will reduce the recurrence. Palliative resection provides symptom free disease when a complete resection is not viable. The tissue transfer for the wound cover controls the residual disease in cases of incomplete resection.

Key words: Vascular Malformations, Free Tissue Flaps, Cardiopulmonary Bypass

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