|Year : 2018 | Volume
| Issue : 1 | Page : 56-57
Arteriovenous malformation in foot: A case report
Pawan Kumar, Ashutosh Kumar, Ritesh Runu, Santosh Kumar, Arnab Sinha, Vidya Sagar, Deepak Kumar, Sheel Avinish
Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
|Date of Web Publication||12-Feb-2018|
Associate Professor, Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
Source of Support: None, Conflict of Interest: None
Arteriovenous malformation is rarely seen in the foot. It is mostly found in the brain, lungs, pelvis and thigh of the lower extremity. It occurs as a result of failed fetal vascular development. It may be associated with dermatologic and osseous manifestations. Chronic ulcerations in foot due to malformation may lead to amputation. Once identified, it should be completely evaluated.
We report a case of an adult female with arteriovenous high-flow malformation of the foot. The diagnostic dilemma has been highlighted.
Keywords: Arteriovenous Malformation, Hemangioma, Soft tissue Mass
|How to cite this article:|
Kumar P, Kumar A, Runu R, Kumar S, Sinha A, Sagar V, Kumar D, Avinish S. Arteriovenous malformation in foot: A case report. J Indira Gandhi Inst Med Sci 2018;4:56-7
|How to cite this URL:|
Kumar P, Kumar A, Runu R, Kumar S, Sinha A, Sagar V, Kumar D, Avinish S. Arteriovenous malformation in foot: A case report. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2022 Aug 10];4:56-7. Available from: http://www.jigims.co.in/text.asp?2018/4/1/56/302989
| Case Report :|| |
We report a case of 32 year-old female who presented with progressive swelling and pain on plantar aspect of right mid foot since 4 years. The swelling was initially painless which gradually became painful on bearing weight. Pain was localized in foot. Locally incision and drainage was done six months back suspecting abscess. The swelling persisted and sonography of right foot was done. It showed diffuse fibromatosis or Giant cell tumour of plantar sheath. Pain was severe enough to prevent her to bear weight on affected foot. Thence she was referred to our institute for further management.
On examination, right foot plantar aspect was swollen, midfoot cavus was obliterated and healed scar mark of previous surgery was present. [Figure 1] On palpation single firm, tender, globular, pulsatile swelling on mid plantar aspect of right foot was present.
|Figure 1: Clinically right foot shows globular localize swelling on mid planter aspect of foot.|
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Hemogram was within normal limit except ESR 32mm/hr and CRP titre 13.2mg/l were raised. FNAC of lesion showed cytomorphological feature of sarcoma similar to rhabdomyosarcoma. Then she was referred to orthopaedic department for excision of mass. Routine X-ray foot was normal. CT angiography right foot showed 8.7cm x 4.1cm hetrogenous enchancing soft tissue lesion in mid foot.
[Figure 2] MRI of foot was suggested to define the extent and location of lesion before excision. The report showed space occupying lesion of nerve sheath of plantar fascia. [Figure 3].
|Figure 2: CT angiography right foot showed 8.7cm x 4.1cm heterogeneous enhancing soft tissue lesion|
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|Figure 3: MRI report showed space occupying lesion of nerve sheath of plantar fascia in right foot.|
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On the basis of radiological report patient was posted for excision of soft tissue tumor with orthopaedic and vascular surgeon. Midline curvilinear incision was planned and consent for vascular injury of foot was taken. As protocol before incision, needle aspiration was done which showed frank blood in the lesion. Operation was postponed and repeat ultrasonography of right foot done. The report showed 5x3 cm high flow vascular malformation. [Figure 4] Once diagnosis of arterio-venous malformation(AVM) vascular surgeon consultation was sought. He decided for sclerogent therapy. Post injection patient was discharged in stable condition. Post injection 4weeks later the pain and swelling reduced and she was mobile on walker with partial weight bearing.
|Figure 4: ultrasonography right foot which shows 5×3 cm high flow vascular malformation|
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| Discussion :|| |
Vascular malformations are of three types - venous, arteriovenous and capillary. It is usually congenital and grows during childhood and adolescence under the influence of trauma or hormonal changes. It has the incidence of 1-10 per million. Cephalic are most common, follow by the trunk, lower and upper extremities. Rarely vascular malformations are part of a syndrome complex like genetic disorders or Klippel-Trenaunay-Weber and Sturge-Weber syndromes, hence family history is essential. One third of vascular tumors (e.g. haemangioma) are visible at birth, rest appears in the first few years of childhood. They are characterized by a rapid growth but spontaneously involutes with time. In contrast, artriovenous malformations increase in size as the child grows.
The Schobinger staging system of arteriovenous malformations includes four stages: expansion, destruction, dormancy, and decompensation. This staging system is useful for documentation of lesion. In our study the lesion was detected in stage three when the pain was unbearable and patient reported for medical help. First ultrasound report was plantar fibromatosis (Ledderhose disease), which is usually seen in both feet between 30-50yrs of age. Pain and nodular swelling are its feature. Our patient was in the same age group and initial feature would have overlapped thus delaying the diagnosis and treatment.
CT angiography and MRI of affected foot was done. CT angiography showed early filling of venous channels proving it to be highflow lesion. Since it doesn’t define the surrounding structures it is not a good investigation to define AVM.
MRI and MR angiography is better tool to define the lesion. It comments on the surrounding structure and also the vessels. The radiation is less compared to CT scan.
Pre - incision aspiration should always be done to define the nature of lesion. In our case we got blood and repeat duplex scan showed high-flow vascular lesion. Duplex sonography is cheap test to define the lesion. It should be done as initial test. It is highly operator dependent. Hence clinical interpretation is essential.
The treatment of vascular lesions is variable. Selective embolism under angiography control and surgical excision are major options. Laser therapy and sclerogent therapy is well established treatment of venous lesions. In our case sclerothrapy has better results. Pain and swelling subsided. We conclude that painful progressive swelling in foot in middle aged population should be well investigated. Duplex sonography is better investigation tool for AVM and needle aspiration should always be done before incision.
| References|| |
Nguyen PD, Cohen OD, Nadler EP. Paediatric surgery: A comprehensive text for Africa. Arteriovenous malformations. Chapter 112, 660-663.
Robbin MR, Murphey MD, Temple T, Kransdorf MJ, Choi J. Imaging of musculoskeletal fibromatosis. RSNA 2001, 21(3): 585-600.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]