Vascular malformations of the upper limb: A review of 270 patients

Vascular malformations of the upper limb were once thought to be impossible to properly diagnose and treat. We reviewed our experience with these malf ormations of the upper limb in 270 patients seen over a 28-year period. The se anomalies were slightly more common in females than males (ratio, 1.5:1. 0). The malformations were categorized as either slow flow (venous, n = 125 ; lymphatic, n = 47; capillary, n = 32; combined, n = 33) or fast flow (art erial, n = 33). Three categories of fast-flow malformations were identified and designated as types A, B, and C. Over 90% of these lesions could be pr operly diagnosed by their appearance and growth pattern within the first 2 years of life. Additional radiographic studies were used to confirm this di agnosis and to define specific characteristics. Magnetic resonance imaging with and without contrast best demonstrated site, size, flow characteristic s, and involvement of contiguous structures for all types of malformations. Algorithms for treatment of both slow-flow and fast-flow anomalies are pre sented. Two hundred sixty surgical resections were performed in 141 patient s, including 24 of 33 fast-flow anomalies. Preoperative angiographic assess ment, with magnified views, was an important preoperative adjunct before an y well-planned resection of fast-flow arteriovenous malformations. The surg ical strategy in all groups was to thoroughly extirpate the malformation, w ith preservation of nerves, tendons, joints, and uninvolved muscle, and mic rovascular revascularization and skin replacement as required. Resections w ere always restricted to well-defined regions and often completed in stages . Symptomatic slow-flow malformations and types A and B fast-flow anomalies were resected without major sequelae. Type C arterial anomalies, diffuse, pulsating lesions with distal vascular steal, and involvement of all tissue s, including bone, progressed clinically and resulted in amputation in 10 o f 14 patients. The complication rate was 22% for slow-flow lesions and 28% for fast-flow lesions. (J Hand Surg 1999;24A:1019-1035. Copyright (C) 1999 by the American Society for Surgery of the Hand.)