Scientific letter
Arteriovenous Malformations in Serratus Anterior Muscle
Malformación arteriovenosa en músculo serrato mayor
Laura Arroyo Pareja
, Francisco García Gómez, María Dolores Barrera Talavera, Francisco Javier de la Cruz Lozano, Nicolás Moreno Mata
Corresponding author
Servicio de Cirugía Torácica, Hospital Universitario Virgen del Rocío, Unidad Medicoquirúrgica de Enfermedades Respiratorias (UMQER), Instituto de Biomedicina de Sevilla (IBIS), Centro de Investigacion en Red de Enfermedades Respiratorias (CIBERES), Sevilla, Spain
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When they are very large, there is a risk of bleeding. This is an added difficulty when planning surgical treatment, and preoperative embolization is occasionally required.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 20-year-old patient with no prior medical history who came to our consultation due to thoracic pain associated with a large chest wall mass that had been growing slowly for 9 years. Examination revealed a poorly defined left lateral thoracic tumor formation measuring 10<span class="elsevierStyleHsp" style=""></span>cm that fluctuated in size, apparently adhered to the muscle plane.</p><p id="par0015" class="elsevierStylePara elsevierViewall">An initial ultrasound of the left periscapular area revealed a heterogeneous nodular focal lesion with poorly defined edges. Color Doppler showed considerably large vessels in its interior, findings that could correspond with a vascular lesion, probably soft tissue hemangioma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to more precisely outline the lesion, a magnetic resonance imaging study was ordered (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which showed evidence of a solid mass in the left serratus anterior muscle measuring 11<span class="elsevierStyleHsp" style=""></span>cm×5.5<span class="elsevierStyleHsp" style=""></span>cm×3.3<span class="elsevierStyleHsp" style=""></span>cm (craniocaudal, anteroposterior and lateral, respectively), that was notably hyperintense in T2, with a winding path and exhibiting signal void phenomenon in its center related with high-flow vessels, denoting the vascular nature of the mass.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We decided to make an incision over the area of the lesion and then removed an oval tumor measuring 8<span class="elsevierStyleHsp" style=""></span>cm×7<span class="elsevierStyleHsp" style=""></span>cm×2<span class="elsevierStyleHsp" style=""></span>cm in the serratus muscle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), whose upper end passed the tip of the scapula, without infiltrating the costal plan. In its interior, there was a conglomeration of vascular-looking elements, some of them with a congestive appearance.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The pathology study reported the lesion to be an arteriovenous malformation.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Arteriovenous malformations are a network of multiple direct communications between arterial and venous branches without capillary network amongst them.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> They often involve the peripheral vascular system although they can occur in any organ.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> They are defects in the circulatory system that generally occur during embryonic or fetal development.</p><p id="par0040" class="elsevierStylePara elsevierViewall">AVM may be classified as either acquired or congenital, which are very rare. Although present at birth, symptoms are usually not seen until adulthood, normally in the second or third decades of life. Acquired forms often result from trauma, cirrhosis, neoplasms or infections.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Depending on their location, arteriovenous malformations may be asymptomatic or, on the contrary, they may cause serious symptoms. There is one published case of chest wall compression due to rupture of an AV fistula.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Likewise, there are reports of mediastinal and intrapulmonary intercostal localizations.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Within the thoracic cavity, pulmonary AVM are the most frequent (2–3 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants), occasionally associated with Rendu–Osler–Weber syndrome.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">AVM can cause symptoms when they are infectious, causing compression of adjacent structures due to their size or bleeding. Symptomatic cases that have been published involved brachycephalic, intercostal and internal mammary arteries,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> most frequently in the right upper extremity, which may be related to the complex embryonic development of the right subclavian artery.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Early diagnosis and appropriate treatment of these lesions are necessary as there may potentially be severe symptoms such as congestive heart failure due to the shunt effect or important bleeding.</p><p id="par0060" class="elsevierStylePara elsevierViewall">On other occasions, the discovery of AVM may be an incidental finding during imaging testing for another cause.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Effective diagnostic tests include Doppler ultrasound, magnetic resonance imaging and angiography, which show the exact vascular architecture of the lesion in cases of high-flow lesions. Ultrasound and MRI were the tests indicated in our patient, since the latter correctly defines the origin of the lesion and its relationship with adjacent structures.</p><p id="par0070" class="elsevierStylePara elsevierViewall">As for treatment, surgical removal is accepted as the definitive treatment, although we must take into account that the results are variable in terms of recurrences and the risk of intraoperative bleeding. Preoperative embolization in order to obliterate the abnormal arteriovenous connections can be useful to reduce bleeding and improve long-term recurrence rates.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We have not found in the literature any cases of intramuscular AVM such as the one presented in our patient. In conclusion, we can say that AVM of the chest wall are uncommon lesions, and that correct differential diagnosis is necessary for proper management. The only symptom of our patient was the sensation of a mass that had been growing since childhood.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-30" "fechaAceptado" => "2012-05-28" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arroyo Pareja L, García Gómez F, Barrera Talavera MD, de la Cruz Lozano FJ, Moreno Mata N. Malformación arteriovenosa en músculo serrato mayor. Cir Esp. 2014;92:58–60.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 992 "Ancho" => 1085 "Tamanyo" => 121291 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Solid mass in the left anterior serratus muscle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 754 "Ancho" => 950 "Tamanyo" => 152895 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Removal of the oval tumor formation from the middle of the serratus muscle.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Giant arteriovenous malformation located on the chest wall—diagnosis and endovascular treatment: report of a case" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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Yang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2143/ACB.66.3.2062559" "Revista" => array:5 [ "tituloSerie" => "Acta Clin Belg" "fecha" => "2011" "volumen" => "66" "paginaInicial" => "242" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21837940" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Congenital intercostal arteriovenous malformation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.P. Rivera" 1 => "M.K. Kole" 2 => "D.M. Pelz" 3 => "I.B. Gulka" 4 => "F.N. McKenzie" 5 => "S.P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 29 | 10 | 39 |
| 2024 September | 62 | 20 | 82 |
| 2024 August | 46 | 22 | 68 |
| 2024 July | 47 | 13 | 60 |
| 2024 June | 41 | 9 | 50 |
| 2024 May | 42 | 8 | 50 |
| 2024 April | 41 | 10 | 51 |
| 2024 March | 45 | 9 | 54 |
| 2024 February | 63 | 6 | 69 |
| 2024 January | 70 | 2 | 72 |
| 2023 December | 72 | 10 | 82 |
| 2023 November | 101 | 8 | 109 |
| 2023 October | 102 | 8 | 110 |
| 2023 September | 41 | 3 | 44 |
| 2023 August | 65 | 7 | 72 |
| 2023 July | 71 | 5 | 76 |
| 2023 June | 71 | 6 | 77 |
| 2023 May | 95 | 7 | 102 |
| 2023 April | 76 | 1 | 77 |
| 2023 March | 76 | 2 | 78 |
| 2023 February | 56 | 7 | 63 |
| 2023 January | 62 | 6 | 68 |
| 2022 December | 42 | 6 | 48 |
| 2022 November | 39 | 8 | 47 |
| 2022 October | 45 | 9 | 54 |
| 2022 September | 39 | 9 | 48 |
| 2022 August | 42 | 11 | 53 |
| 2022 July | 33 | 11 | 44 |
| 2022 June | 23 | 6 | 29 |
| 2022 May | 37 | 8 | 45 |
| 2022 April | 30 | 15 | 45 |
| 2022 March | 44 | 6 | 50 |
| 2022 February | 32 | 3 | 35 |
| 2022 January | 72 | 11 | 83 |
| 2021 December | 29 | 12 | 41 |
| 2021 November | 46 | 7 | 53 |
| 2021 October | 63 | 10 | 73 |
| 2021 September | 67 | 7 | 74 |
| 2021 August | 79 | 8 | 87 |
| 2021 July | 48 | 9 | 57 |
| 2021 June | 40 | 8 | 48 |
| 2021 May | 44 | 9 | 53 |
| 2021 April | 104 | 19 | 123 |
| 2021 March | 188 | 8 | 196 |
| 2021 February | 38 | 14 | 52 |
| 2021 January | 55 | 11 | 66 |
| 2020 December | 43 | 12 | 55 |
| 2020 November | 39 | 18 | 57 |
| 2020 October | 30 | 10 | 40 |
| 2020 September | 41 | 12 | 53 |
| 2020 August | 27 | 18 | 45 |
| 2020 July | 18 | 13 | 31 |
| 2020 June | 21 | 10 | 31 |
| 2020 May | 53 | 6 | 59 |
| 2020 April | 19 | 4 | 23 |
| 2020 March | 30 | 3 | 33 |
| 2020 February | 27 | 2 | 29 |
| 2020 January | 29 | 11 | 40 |
| 2019 December | 30 | 8 | 38 |
| 2019 November | 21 | 6 | 27 |
| 2019 October | 19 | 6 | 25 |
| 2019 September | 15 | 5 | 20 |
| 2019 August | 21 | 5 | 26 |
| 2019 July | 25 | 17 | 42 |
| 2019 June | 32 | 23 | 55 |
| 2019 May | 117 | 72 | 189 |
| 2019 April | 63 | 43 | 106 |
| 2019 March | 14 | 14 | 28 |
| 2019 February | 21 | 8 | 29 |
| 2019 January | 15 | 11 | 26 |
| 2018 December | 12 | 4 | 16 |
| 2018 November | 11 | 5 | 16 |
| 2018 October | 20 | 0 | 20 |
| 2018 September | 24 | 4 | 28 |
| 2018 August | 5 | 2 | 7 |
| 2018 July | 7 | 5 | 12 |
| 2018 June | 4 | 3 | 7 |
| 2018 May | 10 | 4 | 14 |
| 2018 April | 6 | 2 | 8 |
| 2018 March | 7 | 1 | 8 |
| 2018 February | 4 | 4 | 8 |
| 2018 January | 5 | 3 | 8 |
| 2017 December | 7 | 1 | 8 |
| 2017 November | 7 | 8 | 15 |
| 2017 October | 13 | 2 | 15 |
| 2017 September | 7 | 10 | 17 |
| 2017 August | 17 | 4 | 21 |
| 2017 July | 10 | 1 | 11 |
| 2017 June | 15 | 19 | 34 |
| 2017 May | 14 | 6 | 20 |
| 2017 April | 14 | 2 | 16 |
| 2017 March | 17 | 4 | 21 |
| 2017 February | 31 | 2 | 33 |
| 2017 January | 34 | 2 | 36 |
| 2016 December | 27 | 6 | 33 |
| 2016 November | 19 | 4 | 23 |
| 2016 October | 62 | 21 | 83 |
| 2016 September | 118 | 4 | 122 |
| 2016 August | 51 | 6 | 57 |
| 2016 July | 35 | 1 | 36 |
| 2016 June | 32 | 11 | 43 |
| 2016 May | 30 | 15 | 45 |
| 2016 April | 34 | 11 | 45 |
| 2016 March | 36 | 23 | 59 |
| 2016 February | 21 | 9 | 30 |
| 2016 January | 18 | 7 | 25 |
| 2015 December | 19 | 6 | 25 |
| 2015 November | 22 | 10 | 32 |
| 2015 October | 26 | 3 | 29 |
| 2015 September | 31 | 3 | 34 |
| 2015 August | 12 | 6 | 18 |
| 2015 July | 18 | 2 | 20 |
| 2015 June | 14 | 1 | 15 |
| 2015 May | 15 | 4 | 19 |
| 2015 April | 19 | 6 | 25 |
| 2015 March | 16 | 6 | 22 |
| 2015 February | 21 | 2 | 23 |
| 2015 January | 22 | 18 | 40 |
| 2014 December | 51 | 13 | 64 |
| 2014 November | 25 | 2 | 27 |
| 2014 October | 23 | 3 | 26 |
| 2014 September | 20 | 4 | 24 |
| 2014 August | 25 | 4 | 29 |
| 2014 July | 26 | 5 | 31 |
| 2014 June | 15 | 3 | 18 |
| 2014 May | 18 | 1 | 19 |
| 2014 April | 18 | 6 | 24 |
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