右上肢巨大動静脈奇形で大切断に至った2例

Two Cases of Massive Arteriovenous Malformations of a Right Upper Extremity Leading to Major Amputation

はじめに

　巨大動静脈奇形（arteriovenous malformation：以下，AVM）は難病指定となっており 1），治療に難渋する疾患である。安易な切除により再増悪していくこともしばしばで，特にnidusの範囲が広くなれば，外科的切除においても大きな侵襲を伴うことは避けられない。一方，低侵襲で反復治療可能な血管内治療も発展してきており，放射線科医と連携した総合的治療が求められる。今回われわれは，右上肢巨大AVMに対して放射線科で血管内治療を繰り返したが，潰瘍形成，出血や疼痛などのため，当科で大切断に至った2例を経験した。

　Massive arteriovenous malformations (AVMs) are difficult to treat. Partial resection often results in re-exacerbation of the disease, and surgical resection is highly invasive, especially if the nidus is extensive. Minimally invasive and repeatable endovascular treatment has been applied in some cases, but comprehensive treatment in collaboration with radiologists is required for such therapy. We provide the case details of two patients (a 62-year-old woman and a 32-year-old man) who underwent major amputations in our department because of ulceration, bleeding, and pain after they had undergone repeated endovascular treatment by radiologists for massive AVMs in a right upper extremity.

　The common features of the two patients were extensive lesions extending over more than half of the limb, progression of the lesions after repeated endovascular treatment, blood transfusions because of major bleeding, and the patientsʼ reports of excruciating pain. Although the possibility of salvaging the limb in each case was investigated, we ultimately decided that major amputation was indicated in both patients.

　When planning a major amputation of an upper-extremity AVM with extensive lesions, it is important to consider whether the elbow joint can be preserved. If a patientʼs symptoms do not improve to some extent after endovascular treatment of peripheral lesions, it is thus advisable to suggest endovascular treatment around the elbow joint to the radiologist, with a view toward major amputation. It is also possible to shift the treatment plan to allow safe amputation at the level of the forearm, leaving the elbow joint intact.