September 2018

Treating Vascular Malformations Without Surgery

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By Nicole Wetsman

Arteriovenous malformation can be managed non-surgically according to a poster3 presented by Rothman Institute podiatrists Faith Schick, PDM, and Nicholas Taweel, DPM. DPT. Their case report detailed how they resolved the patient’s symptoms and the case, highlighting the opportunities for non-operative treatment in this condition.

Arteriovenous malformations (AVM), a subset of vascular malformations, are tangles of abnormal blood vessels that initially form during fetal development. They can lie dormant, and go on to be identified at any point from infancy through adulthood. They typically appear in the brain, lungs or lower extremities, and are commonly treated through surgical resection.

The patient in this case study, a 50-year-old female nurse, reported four months of pain in her left foot. She was initially diagnosed with plantar fasciitis, but after symptoms worsened, she turned to the authors’ clinic. The physical exam showed normal range of motion with tenderness along the bottom of the center of the foot; an MRI revealed the arteriovenous malformation.

While awaiting the MRI results, the patient had the foot immobilized in a boot for two weeks and reported improvement in symptoms as a result. Noting the improvement, the authors decided to continue immobilization for an additional four weeks, to allow any irritation of the AVM to resolve. After that time, symptoms had resolved even further, and the patient returned to normal activity. At the 1-month follow-up appointment, the patient reported some mild discomfort after a long day on her feet and was given a custom orthotic insert to ease the pressure on the AVM. The orthotic allowed her to return to normal work, as a nurse on her feet most of the day, without pain.

This particular AVM was deep within the foot, and surgical removal would likely have resulted in significant scar tissue, wrote the authors. A treatment approach focused on avoiding surgery, then, helped to avoid those complications. Because the patient had no problems with the AVM prior to when pain developed, it was reasonable to expect that she would be able to return to an asymptomatic state, they said.

“It is our belief that consideration to conservative treatment of AVMs in the foot should be considered prior to surgical treatment in all patients presenting with new onset of symptoms,” wrote the authors in their conclusion.

 

Posters presented at American Podiatric Medical Association 2018 Annual Meeting

  1. Alalwee, A, Spergel, G, Santi, L et al. The Outcomes of Local Flushing of Insulin on Wound Healing in Patients with Diabetic Foot Ulcers.
  2. Moisan, G, Descarreaux, M, Cantin, V, et al. Effects of Two Types of Foot Orthoses on the Biomechanics of Participants with Cavus Feet During Walking.
  3. Schick, F, Taweel, N. A Non-surgical Approach to Arteriovenous Malformation of the Foot.
  4. Brock, K, Walters, J. Is the Operating Room Always Necessary? Office Based Toe Amputations for Osteomyelitis.
  5. Cole, W. Management of Small, Lower Extremity Wounds in the Ambulatory Setting Using a Disposable, Mechanically Powered Negative Pressure Wound Therapy System.
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