Introduction:
In general, arteriovenous malformations (AVMs) are extremely rare, with an incidence of only 1 in 100,000. They are rarer still in the hands and present variably with bleeding, heaviness, a pulsatile mass, pain, ulceration, or necrosis.
Report:
The case of a 25 year old man with a rapidly bleeding right thumb AVM is presented. Bleeding was torrential and life threatening within a matter of seconds. He had previously undergone surgical ligation and embolisation twice at another centre, without success. At presentation, he had no thumb function and the bones of the thumb were exposed. An angio-embolisation was performed with ethanol and cyanoacrylate as the embolic agent. This was done using direct puncture into the AVM and also with a transarterial approach with microcatheters inserted into various unnamed branches feeding the AVM. Non-target embolisation and reflux was prevented by deploying a pneumatic tourniquet and mechanical elastic bands to confine the flow of the embolic agents within the AVM. Re-aspiration of the embolic agent post-embolisation was also performed to prevent local/systemic ethanol toxicity. Haemostasis was achieved without the need for further compression. A right thumb disarticulation was subsequently performed and the patient expressed great satisfaction with the outcome.
Discussion:
AVMs in the hand are particularly challenging to treat owing to the need to preserve function of the myriad tissues and structural units that enable the many hand movements involved in activities of daily living. Even a partial loss of function may be disabling or poorly tolerated. The mainstays of treatment are embolisation, sclerotherapy, and surgical ligation/resection, all of which carry the potential for ischaemic injury to muscle and soft tissue. A holistic approach to management is desirable prior to selecting the appropriate management plan.