Ethanol embolotherapy of foot arteriovenous malformations

Abstract

Objective: To review initial clinical presentation, treatment course, and results of ethanol embolotherapy for foot arteriovenous malformations (AVMs) and to analyze prognostic factors for treatment results.

Methods: Twenty-nine patients (mean age, 31.3 years; range, 9-59) who underwent ethanol embolotherapy between 1999 and 2012 were retrospectively reviewed. Initial clinical manifestation, medical history, treatment results of ethanol embolotherapy, and major and minor complications were reviewed in detail. Two radiologists analyzed the extent of AVM involvement, modified angiographic classification by Cho et al, presence of feeding artery aneurysm, degree of devascularization after embolotherapy, and treatment results. From the analysis, prognostic factors for final outcome were assessed.

Results: The most common symptom was pain (83%; 24/29), followed by ulcer (52%; 15/29), mass (48%; 14/29), varicosity (38%; 11/29), and swelling (31%; 9/29). On baseline angiogram, lesion extent <25% of the foot occurred in 62% (18/29) of cases. Between 25% and 33% comprised 24% (7/29), followed by more than 66% (10%; 3/29) and 33% to 50% (3%; 1/29). The most common modified angiographic type was type IIIa (38%; 11/29), followed by IIIb (31%; 9/29), II (14%; 4/29), IIIa + IIIb (7%; 2/29), and II + IIIa (3%; 1/29). A total of 61 ethanol embolization sessions (range, 1-10; median, 1) were performed in 29 patients. Seventeen of the 29 patients had only one intervention. Transarterial approach was performed in six patients and direct puncture in 11 patients. Twelve patients required both transarterial approach and direct puncture. One patient underwent both coil embolization via direct puncture and transarterial ethanol embolotherapy. Cure (as judged by both completion angiography and clinical improvement) was achieved in seven patients (24%; 7/29). Seventeen patients experienced improvement (59%; 17/29). In three patients, the lesion showed no change (10%). Treatment failure was reported in two patients (7%; 2/29). Major complications occurred in 24% (7/29) and minor complications in 52% (15/29). Skin necrosis (35%; 10/29) was the most common minor complication. Lesion extent had a moderate correlation with outcome (P < .001; ρ = 0.633). Lesions <25% showed 100% success rates with >25% having 55%. There was no correlation between angiographic type and outcome (P > .05; ρ = 0.143).

Conclusions: Ethanol embolotherapy for foot AVMs can be as effective and safe as for other body parts. From the analysis of angiographic findings, foot AVMs that involve <25% of the area of the foot are prone to show better treatment outcomes from ethanol embolotherapy.