PC084. Serious Complications From Embolosclerotherapy of Upper Extremity High- and Low-Flow Vascular Malformations From a Specialist Single Center

Abstract

Minimally invasive, embolosclerotherapy (EST) for upper extremity vascular malformations (VMs) carries significant risk of serious complications, such as ischemia, infarction, amputation, nerve injury, contracture, and ulceration, with as high as 61% rates for hand treatments most recently reported. Despite improved care in specialist centers, up-to-date estimates of complication risk for audit and informed consent are scarce; recent literature focuses on high-flow VMs (HFVM) with a paucity of data for low-flow VMs (LFVM). This study reviews the 5-year serious complications following EST of all upper extremity VM in our tertiary referral center for vascular anomalies. All VM patients underwent multidisciplinary review directed intervention, and demographic, procedural, follow-up, and complication data collected prospectively in a dedicated database. Treatment outcomes for upper extremity VM from January 1, 2013, to December 31, 2017, were analyzed (Figures 1 and 2). EST interventions were performed under fluoroscopic guidance. All ESTs of HFVM were performed under selective catheter angiography and direct injection, but LFVM with direct injection only. Serious complications were defined as any tissue or functional damage caused by direct injection, distal embolization, or tissue reaction. There were 70 patients who had a total of 150 EST procedures for upper extremity VMs (median age, 24.5 years; range, 1-73 years; 44 male, 26 female). Of these, 28 (40%) had EST for HFVM and 42 (60%) for LFVM (total 78 and 72 procedures, respectively). Most used agents were foam sclerosant (STD 3% mixed in ratio 2:8 with air), dehydrated absolute ethanol, and coils. Serious complications as follows: HFVM in five patients (17.9%) or 6.4% of total procedures; three ischemia of fingers and/or hand requiring amputation (Figs 1 and 2), and two skin ulcerations. Serious complication in LFVM occurred in five patients (11.9%) or 6.9% of total procedures: one median nerve injury causing wrist drop requiring nerve grafting and hand therapy, one hand contracture requiring tendon release, and three skin ulcerations. All ulcerations resolved without significant long-term disability. However, the nerve and tendon injuries carried degrees of long-term functional disability. Current EST is relatively safe for upper extremity HFVM where our complication rate of 17.9% compares favorably with the recent literature, possibly owing to the selective use of foam versus alcohol, and improved classification and targeted treatment. For LFVM, significant complications resulted in 11.9% of patients from local toxicity after direct injection. These outcomes will direct treatment strategies to avoid local toxic complications in the hand for both HFVM and LFVM, and to informed consent.Fig 2After amputations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)