Adjuvant role of anti-angiogenic drugs in the management of head and neck arteriovenous malformations.

Arteriovenous malformations (AVMs) are high-flow vascular malformations characterised by a complex vessel network directly connecting feeding arteries and draining veins, typically featured by a natural history of progression, while spontaneous regressions are purely anecdotal. AVMs are very aggressive entities that possess a locally infiltrative behaviour like neoplasms. Complete "radical" surgical excision presents the highest chance of cure, but nowadays there is still considerable controversy on how to treat large AVMs that are not amenable of "radical" excision. The aim of this paper is to propose a different approach to treat vast AVMs that cannot be removed radically. The association of an antiangiogenic drug (to be initiated before surgery and to be continued in the post-operative period), could prevent the feared "explosive" growth of the remaining nidus after its partial removal. This could make recontouring and other "aesthetically" focused procedures feasible in these patients, with an obvious leap in their quality of life. The most promising antiangiogenic drug seems to be Thalidomide, but other drugs such as Sirolimus, VEGF pathway inhibitors, Interferon or Matrix Metalloproteinase (MMP) Inhibitors could serve the purpose just as well. Even Propranolol could prove useful in this sense as suggested by some recent researches on retinopathy of prematurity and tumour biology.