Multidisciplinary Approach to the Management of Head and Neck Vascular Malformations – Towards a Change of Treatment Paradigm

Objectives: Vascular malformations are challenging to diagnose and treat. They are classified as high-flow [arteriovenous malformation (AVM)] or low-flow [venous malformations (VM), lymphatic malformations (LM), venous-lymphatic malformations (VLM)]. They may be presented as minor, focal soft tissue lesions, or extensive, diffuse, combined soft and hard tissue lesions. The objective of the present study was to evaluate management strategies and treatment outcomes, and to offer lessons learned from our experience.

Methods: Retrospective cross sectional study, including individuals diagnosed with head and neck vascular malformations, treated by an interdisciplinary teem.

Results: Sixty patients were included, 44 adults and 16 children. Diagnosis included VM (42), LM (5), VLM (5), AVM (8). Focal, superficial lesions were diagnosed clinically. Dynamic magnetic resonance angiography was used to determine the flow nature of more diffused penetrating lesions. Digital subtraction angiography was done in cases suspected for AVM. Twenty-three cases were managed by follow-up alone, while 37 enrolled for treatment. Indications for treatment included pain, bleeding and aesthetic disturbance. VMs, LMs and VLMs were treated by sclerotherapy (23), surgery (8), or their combination (1). Complete resolution achieved in 33 cases (90%), with minimal adverse effects. One nonsurgical LM case was treated by Sirolimus with good, nevertheless, partial effect. AVMs were managed by combined treatment of embolization via therapeutic interventional radiology, direct sclerotherapy and surgery. Although the treatment resulted in partial clinical regression, it allowed to sufficiently relieve symptoms with minimal morbidity.

Conclusions: The treatment of focal VMs/LMs is usually predictable with high success rates, using either sclerotherapy, surgery, or their combination. AVMs demonstrate highly complex and recidivistic disease. Definitive treatment carries the risk for complications and usually results in high morbidity. Advance vascular disease requires multidisciplinary staged treatment strategy aiming to improve symptoms, to increase treatment intervals, and to control the disease, rather than to cure it.