Scalp Arteriovenous Malformation: Double Row Purse String Suture (DROPS) Technique to Decrease Intra-operative Bleeding

Abstract

Scalp arteriovenous malformations (AVMs) are high flow lesions with complex vascular anatomy. Excessive bleeding is a frequent surgical complication in resection of these lesions, for which many techniques have been suggested. Percutaneous suturing of the feeding vessels along with careful blood pressure control is reported as a method to reduce intra-operative bleeding. Skin shortage is a problem during skin repair and skin graft is often needed, but this problem has not been encountered with the present technique. Scalp AVMs without intracranial involvement are candidates for this technique. Patients are prepared for open surgical resection of the scalp AVM. After routine preparation, a double row of continuous interlocking purse string sutures are placed around the lesion periphery, deep to the galea, to temporarily interrupt the feeding arteries (Fig. 1). Then, the overlying skin is incised and skin flaps created by shaving the nidus from skin and then from the deep fascia in a bloodless field (Fig. 2). Next, the feeding arteries and draining veins are ligated. The skin is closed primarily, covered by a tie over compression wound dressing. Finally, the purse string sutures are removed. There was no need for blood transfusion and no significant change in haemoglobin after the procedure in any of our cases.Figure 2Creation of skin flaps and excised lesion in a bloodless field.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Five patients were operated on using the technique. On long term follow up (mean ± standard deviation 5.5 ± 1.5 years) the cosmetic result was promising, without recurrence. Surgical resection can be performed with confidence in a bloodless field without needing a skin graft. This technique has been used in other body parts, but owing to the bony skull, it is more efficient for scalp AVMs.