Evidence-Based Management of Vascular Malformations

Abstract

Vascular malformations of the head and neck are complex lesions that are notoriously difficult to manage. Treatment of these lesions often requires a multispecialty and multimodal approach. In the modern era of evidence-based medicine, it has become imperative for clinicians to incorporate evidence-based treatment algorithms into their everyday practices. With general widespread inundation of the literature with levels IV and V clinical evidence, however, it is often difficult to draw meaningful conclusions that can be practically applied to the clinical question at hand. When asking how best to manage the most common vascular malformations, we are faced with this large volume of lower level studies conducted in drastically different ways without consistency in outcomes reporting, thus making direct comparison nearly impossible. Furthermore, much of the evidence shows mixed results, adding to confusion over what the optimal evidence-based treatment approaches truly are. In attempt to derive consensus from available literature discussing the management of vascular malformations, we reviewed the current literature detailing modern-day treatment approaches for lymphatic malformations, venous malformations, and arteriovenous malformations of the head and neck.

Analysis of mTOR pathway expression in lymphatic malformation and related diseases

“…The mTOR pathway is involved in various pathological mechanisms of lymphangiogenesis, lymphatic metastasis and several cancer developments, including colorectal cancer, gastric cancer, liver cancer, breast cancer and uterine cancer 15–17 . Sirolimus known as a mTOR inhibitor has an antiproliferative effect on lymphatic vessels, and is clinically used for a difficult‐to‐treat lymphatic anomalies 12,13,18–20 . Sirolimus binds the FK‐binding protein 12, resulting in a complex that prevents phosphorylation and activation of 4EBP1 and S6K1 21,22 .…”

Management of a large diffuse maxillofacial arteriovenous malformation previously treated with ligation of ipsilateral arterial supply

“…Embolization or surgery, as a unique treatment or in combination, has been shown to be potentially curative. 10,12 However, surgery is not always feasible due to the diffuse and deep extension of some malformations and their extensive collateral recruitment, such as in our patient. Unfortunately, malformations of this complexity are mostly incurable with either embolization alone or post-embolization excision.…”

“…12 Under such circumstances, subsequent mechanical obliteration is not likely and the role of antiangiogenic drugs will need to be further explored. In addition to bevacizumab and bleomycin, there is a renewed interest in the use of thalidomide as a therapeutic agent for these lesions.…”

Arteriovenous malformation after punch biopsy clinically mimicking a basal cell carcinoma: Case report and review of literature

“…AVM's and BCC's manifests with clinical overlap but can be distinguished by dermoscopy and histological assessment. An early accurate diagnosis of AVM's is important since patients receiving surgical intervention sooner will have a better outcome 5, 14…”