The challenge of large vascular malformations

Vascular malformations are of the low- or high-flow variety, the latter variety also having shunting characteristics. In this manuscript, significant and challenging conditions will be presented. The high-flow lesions can cause excessive growth in the local area, and severe bleeding is always a possibility, either spontaneous or during surgery. Clinical examination, angiography, and Doppler studies confirm the diagnosis. In treatment of the above-mentioned high-flow lesions, embolization is temporary and should be employed mainly as an aid prior to surgery. Nonpermanent material is used. At the time of resection, an inflow vessel is preserved for later embolization should there be a recurrence. Otherwise, treatment may be extremely hazardous with significant blood loss. Resection is performed post-embolization in order to reduce bleeding. Free tissue transfer is frequently needed post-resection. These procedures will often involve cooperation with neurosurgery, vascular surgery, maxillofacial surgery, or ENT surgery. Very occasionally, cardiac arrest and bypass may be necessary, but only after considerable assessment. This can result in severe blood loss in the warming phase. Sotradecol injections have been used during surgery to prevent bleeding in a sclerose-as-you-go technique. Free tissue transfer may produce a new vascular environment, and it is our impression that there is less recurrence after the use of this technique. When there is severe, almost uncontrollable bleeding, large sutures are used to compartmentalize the area and reduce the blood flow followed by injection of sclerosants. This can make resection feasible. Lymphovenous and venous malformations present their own problems. Intralesional therapy is the treatment of choice for these low-flow lesions. If this is unsuccessful, they can be resected but hemostasis can be difficult. All the therapeutic tricks may have to be used: compartmentalization, Sotradecol, and then resection. Again, there is always concern about recurrence.