Number Of Arteriovenous Malformations Research Articles

Arteriovenous malformations (AVMs) represent a common etiology of small bowel bleeding. While guidelines generally recommend treatment for actively bleeding AVMs, management of non-bleeding lesions is less clear. The primary aim of this study was to determine if the number of non-bleeding small bowel AVMs seen on capsule endoscopy (CE) predicts subsequent gastrointestinal (GI) bleeding risk. The secondary aim was to compare the efficacy of medical vs endoscopic therapy in patients with non-bleeding AVMs. A retrospective review of patients who underwent CE between January 2014 and June 2019, primarily for iron deficiency anemia or overt GI bleeding, was conducted. In patients with non-bleeding AVMs on CE, the number of AVMs was analyzed as both a continuous and categorical variable (1 AVM, 2-5 AVMs, or >5 AVMs). The frequency of medical (iron or somatostatin analogue) or endoscopic treatment was determined. Rebleeding incidence at 30- and 90-days post CE was defined by a declining hemoglobin (Hb) or overt GI blood loss. Variables including age, anticoagulation, Hb level, Charlson Comorbidity Index (CCI), chronic kidney disease (CKD), von Willebrand disease (vWD), and hereditary hemorrhagic telangiectasia (HHT) were analyzed. Wilcoxon rank sum test, Fisher’s exact t-test, and student’s t-test were used for comparisons. 109 patients (mean age 66 years; 54% F) with non-bleeding AVMs on CE were identified (33 pts had 1 AVM, 63 pts had 2-5 AVMs, 13 pts had >5 AVMs). Only 9.1% (n=10) and 14.7% (n=16) of total patients had rebleeding at 30 and 90 days, respectively. The number of AVMs on CE was not associated with the risk of rebleeding at either follow-up period (Table 1). Most patients were treated with medical therapy only (74.3%), compared to medical + endoscopic therapy (16.5%) or no therapy (9.2%). The number of AVMs on CE did not predict undergoing medical vs endoscopic treatment. For patients with 1 AVM, 2-5 AVMs, or >5 AVMs, there was no significant difference in the rate of rebleeding at 30 or 90 days when comparing medical vs medical + endoscopic treatment (Table 2). Even in patients predisposed to bleeding (vWD + HHT), there was no significant difference in 30- or 90-day rebleeding rates based on the number of non-bleeding AVMs. However, older age (p<0.001), lower Hb (p<0.001), higher CCI (p<0.001), anticoagulation use (p=0.03), CKD (p=0.01), and vWD (p<0.001) were significantly associated with an increased 90-day rebleeding risk. Non-bleeding AVMs seen on CE bestow a relatively low risk of rebleeding within 90 days. Medical therapy was non-inferior to endoscopic treatment, irrespective of the number of non-bleeding AVMs on CE. While the number of AVMs on CE was not predictive of rebleeding risk, advanced age, anticoagulation use, and comorbidities may better guide rebleeding risk stratification.Table 2Rate of Rebleeding at 30 and 90 days Stratified by the Number of Non-Bleeding AVMs and Treatment ModalityView Large Image Figure ViewerDownload Hi-res image Download (PPT)