Riles T S, Berenstein A, Fisher F S, Persky M S, Madrid M
Department of Surgery, New York University Medical Center, NY 10016.
J Vasc Surg. 1993 Mar;17(3):491-8. doi: 10.1067/mva.1993.38109.
Until recently, the accepted management of life-threatening complications of unresectable cervicofacial arteriovenous malformations (AVMs) has been ligation of the major feeding vessels, usually the branches or the main trunk of the external carotid artery. Rapid enlargement of collateral vessels around the ligature is usually associated with an early return of symptoms. Percutaneous transcatheter embolization of the nidus of the arteriovenous malformation is now the preferred treatment for symptomatic AVMs that cannot be excised. Previous ligation of the main feeding vessels prevents catheter access and embolization therapy of the lesion. The purpose of this report is to describe our experience with the treatment of patients with symptomatic unresectable cervicofacial AVMs and previous external carotid artery ligation.
Six patients with symptoms from cervicofacial arteriovenous malformations required surgical reconstruction of their previously ligated external carotid artery with the anticipation of catheter embolization therapy to the branch vessels feeding the malformation. Saphenous vein was used in five reconstructions; a polytetrafluoroethylene graft was used in one.
After successful arterial reconstruction, massive swelling of the tongue and perioral tissue developed in two patients, which necessitated tracheostomy in one patient; and embolization therapy before extubation could be safely performed in the other patient. In all, four patients underwent successful embolization therapy. One refused subsequent treatment. In one patient with severe epistaxis, external carotid artery revascularization led to the healing of the nasal ulcers without need for embolization therapy.
For patients with previous ligations of the external carotid artery and symptomatic AVMs, revascularization of the external carotid artery is an important step in treatment. The surgery must be carefully coordinated with the interventional radiologist for possible emergency postoperative embolization therapy. External carotid artery ligation only complicates the treatment of patients with cervicofacial AVMs, and should no longer be used in the treatment of these individuals.
直到最近，对于无法切除的颈面部动静脉畸形（AVM）危及生命的并发症，公认的治疗方法一直是结扎主要供血血管，通常是颈外动脉的分支或主干。结扎部位周围侧支血管的迅速扩张通常与症状早期复发相关。对于无法切除的有症状AVM，经皮经导管栓塞畸形病灶现在是首选治疗方法。先前结扎主要供血血管会妨碍对病灶进行导管介入和栓塞治疗。本报告的目的是描述我们对有症状且无法切除的颈面部AVM以及先前已结扎颈外动脉的患者的治疗经验。
6例有颈面部动静脉畸形症状的患者，需要对先前结扎的颈外动脉进行手术重建，以期对为畸形供血的分支血管进行导管栓塞治疗。5例重建手术使用了大隐静脉；1例使用了聚四氟乙烯移植物。
动脉重建成功后，2例患者出现舌部和口周组织大量肿胀，其中1例患者需要行气管切开术；另1例患者在拔管前可安全地进行栓塞治疗。总共有4例患者成功接受了栓塞治疗。1例患者拒绝后续治疗。1例严重鼻出血患者，颈外动脉血运重建使鼻溃疡愈合，无需进行栓塞治疗。
对于先前已结扎颈外动脉且有症状的AVM患者，颈外动脉血运重建是治疗的重要一步。手术必须与介入放射科医生仔细协调，以便可能在术后进行紧急栓塞治疗。颈外动脉结扎只会使颈面部AVM患者的治疗复杂化，不应再用于这些患者的治疗。
