无水乙醇栓塞治疗颅面部动静脉畸形的现状与进展

无水乙醇栓塞治疗动静脉畸形已初步取得了令人满意的临床效果,并展现出良好的应用前景,从而为彻底治愈动静脉畸形提供了一条崭新的途径。但是,无水乙醇栓塞治疗动静脉畸形是一项极具挑战性的工作,如应用不当,会引起一系列并发症,并可导致严重后果。本文对无水乙醇栓塞治疗动静脉畸形的机制、技术要点、栓塞治疗后的病理生理变化、栓塞并发症及其防治作一综述。     

经皮穿刺数字减影血管造影引导下无水乙醇介入栓塞治疗口腔颌面部动静脉畸形

目的探讨应用无水乙醇在数字减影血管造影(DSA)引导下经皮穿刺栓塞治疗口腔颌面部动静脉畸形的可行性和安全性。方法对2012年3月至2016年1月在徐州市中心医院口腔科进行DSA引导下经皮穿刺无水乙醇介入栓塞治疗的9例口腔颌面部动静脉畸形患者进行跟踪随访,评价其临床症状和影像学的改善情况。结果 9例口腔颌面部动静脉畸形患者中5例完全消退,2例消退率≥50%,2例消退率25%~50%。均未发生脑栓塞、肺栓塞、心脏衰竭等严重并发症,面型及功能保存良好。结论 DSA引导下经皮穿刺无水乙醇介入栓塞治疗口腔颌面部动静脉畸形安全有效。     

无水乙醇硬化治疗头颈部静脉畸形的并发症及其预防

目的:分析无水乙醇硬化治疗头颈部静脉畸形的并发症,探讨其预防措施.方法:回顾83例应用经皮穿刺无水乙醇硬化治疗头颈部静脉畸形的临床资料,分析其并发症,探讨其发生原因及预防措施.结果:无水乙醇平均注射总量为15mL,28例(28/83)发生并发症,其中包括面神经麻痹12例,开口受限8例,皮肤、黏膜溃疡2例,乙醇过敏1例和血红蛋白尿5例;无肝肾功能损害及肺动脉痉挛、肺动脉栓塞等并发症.除1例发生面神经额支永久性麻痹外,其他所有并发症经相应处理均治愈.结论:无水乙醇硬化治疗头颈部静脉畸形是安全有效的方法,其并发症可以接受,但此项技术需由有经验的医师操作.     

颌面部创伤性动静脉畸形的临床治疗分析

目的 探讨颌面部创伤性动静脉畸形(AVMs)的治疗方法.方法 2006-2011年东南大学附属徐州医院口腔颌面外科共收治5例颌面部创伤性AVMs患者,根据病程及病变累及范围将其分为急性和慢性创伤性AVMs;2例急性动静脉畸形行手术切除,3例慢性动静脉畸形采用动脉血管内无水乙醇栓塞加局部穿刺无水乙醇栓塞的治疗方法(双介入治疗).结果 所有病例经过0.5～6年的随访,手术治疗2例治愈;“双介入治疗”2例治愈,1例好转,无严重并发症发生.结论 动脉血管内无水乙醇栓塞加局部穿刺无水乙醇栓塞治疗是治疗创伤性AVMs的一种有效、安全的方法.     

射频消融技术联合DSA引导下无水乙醇介入治疗口腔颌面部难治性动静脉畸形的疗效观察

目的 探讨射频消融技术联合数字减影血管造影（digital subtraction angiography,DSA）引导下无水乙醇介入治疗难治性口腔颌面部动静脉畸形的可行性,评价其临床疗效及安全性。方法 2014年3月—2016年4月,应用射频消融技术联合DSA引导下无水乙醇介入栓塞治疗7例口腔颌面部动静脉畸形患者（男4例,女3例）,密切随访,根据患者的临床症状、不良反应、并发症以及影像学资料的变化进行疗效观察及评价。结果 6例有效,1例无效,治疗有效率为85.7%。未观察到严重并发症发生。结论 射频消融技术联合DSA下无水乙醇介入栓塞治疗难治性口腔颌面部动静脉畸形的近期疗效及安全性良好,可能成为其重要的治疗方式。     

经皮穿刺DSA引导下无水乙醇硬化治疗头颈部静脉畸形

目的：探讨DSA引导下无水乙醇硬化治疗头颈部静脉畸形的效果。方法：对2006年3月-2008年4月间应用DSA引导下无水乙醇硬化治疗的53例头颈部静脉畸形患者进行回顾分析,采用影像学及问卷调查的方法评价治疗效果,并对治疗并发症进行分析。结果：所有患者均对治疗效果满意。术后MRI显示,12例病变完全消退,32例消退率≥50%,7例消退率25%～50%,2例消退率〈25%。并发症包括暂时性面神经麻痹、皮肤黏膜溃疡,除1例发生永久性面瘫外,其余并发症经处理均消失。无肺动脉痉挛及肺动脉栓塞严重并发症。结论：DSA引导下无水乙醇硬化治疗头颈部静脉畸形是一种安全有效的方法。     

动静脉畸形无水乙醇栓塞治疗时异常血流动力学波动

目的:总结无水乙醇栓塞治疗动静脉畸形过程中血流动力学的异常波动情况,探讨其规律并试图分析其原因。方法:选择我院日间病房择期于全身麻醉下行无水乙醇栓塞治疗时出现异常波动的动静脉畸形患者12例,记录动静脉畸形注射无水乙醇前后有创血压、心率、脉搏氧饱和度及呼气末二氧化碳分压的变化情况。结果:注射无水乙醇前血压平均为(98.6±6.5)mmHg/(53.1±3.3)mmHg,心率平均为(82.8±11.5)bpm;注射无水乙醇后,心率先明显增快、再下降、最后恢复到注射前水平,最高值平均高达(98.8±13.5)bpm;血压先下降、再上升、再逐渐恢复到注射前水平,最低值平均为(73.7±6.3)mmHg/(39.3±4.8)mmHg;该段时间脉搏氧饱和度及呼气末二氧化碳分压无明显变化。结论: 动静脉畸形注射无水乙醇后数分钟内血压、心率可能出现明显的异常S形波动,确切原因有待进一步研究,但术中需加强监测,必要时予以纠正,以减少并发症的发生。     

无水乙醇在血管畸形治疗中的应用

无水乙醇治疗血管畸形的探索充满挑战,但最终是有益的。过去10年,我们获得了大量关于血管畸形影像学特征和病理学分类的知识。现在,我们相信,许多静脉畸形和动静脉畸形可通过乙醇治愈,某些难以治愈的病灶,也常常可通过乙醇栓塞控制病情或改善症状。乙醇治疗可能引起严重并发症,因此我们强烈建议,这类疾病的治疗应由经验丰富的专科医师实施。我们认为,乙醇栓塞是目前血管畸形这类极其复杂难治的疾病的首选治疗技术。     

气管切开全麻下无水乙醇栓塞治疗咽喉部静脉畸形20例报道

目的 分析咽喉部静脉畸形的治疗方法和效果。方法 总结我院2011年3月—2015年6月收治的咽喉部静脉畸形患者20例,在气管切开下行咽喉部静脉畸形无水乙醇栓塞治疗。结果 15例患者经2次无水乙醇栓塞后咽喉部静脉畸形萎缩并治愈。5例患者合并Ⅱ、Ⅲ度呼吸道阻塞,颞面、下颌、舌体及口底弥漫性静脉畸形行无水乙醇栓塞后,气道阻塞症状治愈,颌面部青斑褪色,静脉畸形缩小并恢复颌面部正常形态;其中3例合并巨舌,行舌体静脉畸形切除成形术取得成功。咽喉部静脉畸形治愈后随访2年未见复发,治愈率50%,有效率100%。结论 咽喉部静脉畸形应早期治疗,气管切开下行无水乙醇栓塞治疗是治愈咽喉部静脉畸形的有效方法。     

Yakes教授对无水乙醇栓塞治疗静脉畸形和动静脉畸形的学术贡献

Yakes教授是国际脉管性疾病研究学会（ISSVA）前任主席,世界著名的血管神经介入治疗专家。早在80年代中期,Yakes教授等就致力于无水乙醇栓塞介入治疗动静脉畸形的研究工作。经过大量动物实验和临床应用,终于获得成功。目前,无水乙醇栓塞治疗静脉畸形、淋巴管畸形和动静脉畸形已经被世界广泛接受并用于临床，造福广大患者。     

乙醇加明胶海绵经动脉栓塞治疗颌面部蔓状血管瘤

目的使用无水乙醇加明胶海绵颗粒经供养动脉栓塞治疗颌面部蔓状血管瘤。方法６例颌面部蔓状血管瘤病例行单纯栓塞治疗术，经颈外动脉造影后以纯酒精加明胶海绵颗粒穿刺供养动脉做永久性栓塞治疗。结果本组病例随访２～１３．５个月未见复发。结论乙醇加明胶海绵栓塞治疗颌面部蔓状血管瘤可取满意疗效。     

Interdisziplinäres Konzept zur Diagnostik und Therapie gefäßreicher Fehlbildungen im Gesichts- und Halsbereich

Purpose. In patients with extended vascular anomalies in the head and neck, therapeutic decisions may pose a challenge to maxillofacial surgeons, dermatologists, and interventional radiologists. We analyzed the value of an interdisciplinary classification and treatment concept. Patients and methods. The classification distinguishes hemangiomas and vascular malformations. Whereas hemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies, which are further classified into high-flow or low-flow lesions and according to the vascular channels into capillary, venous, or lymphatic malformations. Since 2000 we have provided interdisciplinary consultation for patients with vascular anomalies. In patients with hemangiomas and venous malformations, the clinical diagnosis is confirmed by color-coded duplex sonography and magnetic resonance imaging; angiography is performed as part of the treatment planning for patients with arteriovenous malformations. Patients with hemangiomas are treated surgically by cryosurgery or laser surgery or conservatively according to lesion size and behavior. In patients with venous malformations, percutaneous sclerotherapy is combined with surgical reduction; patients with arteriovenous malformations undergo transarterial embolization prior to surgical excision of the nidus. Results. A total of 73 patients attended the interdisciplinary consultation. This group included 53 patients with facial hemangiomas, 7 with venous malformations, 2 with capillary malformations, 5 with lymphatic malformations, and 6 with high-flow arteriovenous malformations. Conclusions. The interdisciplinary protocol increases diagnostic accuracy and helps to establish individual treatment plans for patients with extended vascular anomalies.     

Extensive facial vascular malformations and haemangiomas: a review of the literature and case reports

We present 6 selected cases of extensive facial vascular anomalies extending to the skull base or actually involving it. These patients are compared with other cases in the literature. The spontaneous course of these vascular lesions is different and so variable treatment modalities are suggested depending on the age of the patient and the type of lesion. In young children, haemangiomas are common and spontaneous involution is characteristic. Conservative treatment in the sense of a wait-and-see approach is thereby favoured if these is no urgent indication such as involvement of essential structures, e.g. blockage of an orifice as demonstrated in one case or complications such as excessive bleeding.Vascular malformations most commonly appear in adults, there is no tendency to spontaneous involution and resection is usually necessary, especially in arteriovenous malformations. Nowadays, preoperative superselective embolization is recommended to minimize intraoperative blood loss. Superselective embolization is the treatment of choice in cases of a-v fistulae. Proximal ligation of the supplying arteries should be avoided because this may make embolization more difficult, and may be responsible for the common occurrence of rapid revascularization.     

彩色多普勒超声在颌面部血管畸形诊断、分类及疗效评价中的应用

目的：评价彩色多普勒超声在颌面部血管畸形诊断、分类及疗效评价中的作用。方法：对110例颌面部血管畸形进行二维及彩色多普勒超声检查,根据超声特点,将其分为高流速病变和低流速病变。对DSA检查证实为高流速血管畸形者,常规行供血动脉栓塞治疗。所有数据采用SPSS10.0软件包进行t检验和χ2检验。结果：110例血管畸形中,67例二维显示形态不规则的网格状混合性回声,部分伴强回声静脉石,多谱勒显示彩色血流稀少或较丰富,动脉收缩峰血流速度（PSV）平均为（28.53±8.1）cm/s,超声诊断为低流速血管畸形。43例显示72条供血动脉增粗,病变内血流信号极丰富,PSV平均为（144.53±38.9）cm/s,呈低阻动脉型频谱,超声诊断为高流速血管畸形。经DSA检查或术后病理证实,高流速和低流速病变的超声诊断正确率分别为100%和97.02%。43例高流速血管畸形的供血动脉全部行栓塞治疗,栓塞前、后的PSV分别为（144.53±38.9）cm/s和（86.2±36.3）cm/s,阻力指数（RI）分别为（0.55±0.04）和（0.80±0.05）（P均〈0.01）。结论：彩色多普勒超声检查能对血管畸形病变做出较正确的诊断和分类,对临床选择合理的治疗方案及动脉栓塞术后疗效评价均具有重要的指导意义。     

Pediatric vascular lesions

The seminal work of Mulliken and Glowacki in 1982 elucidated the histological differences between hemangiomas and vascular malformations: the former are characterized by endothelial cell proliferation, whereas the latter contain mature endothelial cells. Hemangiomas proliferate and then involute, whereas malformations remain stable in size, growing proportionally with the child. Vascular malformations are classified by the predominant vessel type within the lesion (capillary, venous, arterial, and lymphatic). Histological classification therefore correlates with clinical behavior. Treatment of hemangiomas is generally conservative; however, intervention may be required as a result of cosmetically concerning, function-threatening (e.g., interference with eyesight), or life-threatening (e.g., airway obstruction) lesions. Options include steroid therapy, laser treatment, and/or surgical excision. Vascular malformations do not involute and are more likely to require treatment. Treatment options include embolization and surgical resection. Understanding the clinical course of pediatric vascular lesions allows the surgeon to find an appropriate balance between watchful observation, providing reassurance when appropriate, and intervention when needed.     

An alternative approach to maxillofacial arteriovenous malformations with transosseous direct puncture embolization

The management of arteriovenous (AVM) malformations of the jaws is complex and requires an integrated team approach. Subspecialists, such as maxillofacial surgeons, interventional radiologists, and critical care intensivists, are commonly involved in the management of these patients. The current treatment options for maxillofacial AVMs are surgical resection combined with endovascular embolization. Surgical treatment of arteriovenous malformations has been associated with significant morbidity and mortality due to potential for massive blood loss. In the pediatric population extensive resection of the craniofacial skeleton may be associated with growth disturbance, functional compromise, and cosmetic deformity. We report a novel technique using endovascular embolization via direct transosseous puncture for a high-flow vascular malformation, obviating the need for extensive surgical resection, and review the important clinical aspects of these life-threatening lesions.     

颌骨内血管畸形的治疗

目的 :总结治疗颌骨内血管畸形的临床经验。方法:回顾分析 6例临床收治的颌骨内血管畸形的病例。结果:颌骨内血管畸形常同时伴有软组织病变 ,牙龈出血是最常见的临床症状 ,轻微外伤或拔牙操作可导致严重出血。颈外动脉结扎栓塞可以作为应急止血措施 ,也可在术前或术中应用以减少手术失血。结论 :颈外动脉结扎栓塞加手术切除即刻整复是根治颌骨血管畸形的最有效措施之一。     

Use of the radial forearm artery for secondary embolization of an extensive life-threatening arteriovenous malformation of the mid-face and anterior skull base – A case report

BackgroundArteriovenous malformations (AVM) of the head and neck are rare conditions with the majority of primary sites in the mid-face. Progression can lead to massive life-threatening bleeding. Treatment of choice is the combination of embolization and surgical resection. Diagnosis and management of AVM has been facilitated in recent years by the progress in imaging techniques and various microsurgical and endovascular embolization procedures.MethodsThis report presents the interdisciplinary approach to a case of life-threatening AVM of the mid-face in a 30-year-old patient.ResultsAngiography with embolization followed by resection and plastic reconstruction was performed. Follow-up showed incomplete obliteration of the AVM and lead to additional embolizations via the anastomosed radial artery. Complete eradication of the AVM was not possible during the three year follow-up period.ConclusionIn extensive vascular malformations of the head and neck, complete surgical removal is often impossible and associated with high risk of complications and mortality. Endovascular embolization is limited by the location of the AVM and can potentially cause stroke, ischaemia, necrosis, bleeding, blindness and adverse haemodynamic changes.