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ARUBA No Reason to Kick Back, Says Dr. Solomon

Aruba tree cropped
A vacation from complexity works well in the real Aruba–but the ARUBA study makes things a little too simple. Image credit: Neil Bledsoe

Treating Arteriovenous Malformations (AVMs) is notoriously tricky. Each AVM, or abnormal tangle of blood vessels in the brain, is as unique as the patient with the AVM him- or herself.

In 2013, researchers conducted a study that they hoped might help doctors treat these complicated cases. Even the name of the study is complicated: A Randomised trial of Unruptured Brain Arteriovenous malformations. Its acronym, though, is easy and breezy: ARUBA.

But Dr. Robert Solomon, Department Chair and neurosurgeon at the Cerebrovascular Center at Columbia University Medical Center / New York Presbyterian Hospital, says the ARUBA study falls short. He points out in the medical journal The Lancet that ARUBA doesn’t really help doctors treat AVMs, in part because the study ignores these cases’ important complexity.

Weighing many factors

The ARUBA study, writes Dr. Solomon, “treats all unruptured [AVMs] the same.” It doesn’t account for the many factors that doctors must consider when deciding whether and how to treat an AVM. AVMs come in different sizes and appear in different areas of the brain; they are set up differently with respect to veins or aneurysms; they occur in patients of different ages and with different health conditions. Doctors must evaluate all these factors and decide on the best way to treat each individual patient and his or her unique AVM.

The ARUBA study also lumps all types of treatment together. In fact, treatment options can be almost as complex as AVMs themselves. Columbia’s Cerebrovascular Center, for instance, has surgeons skilled in treatments like gamma knife, linear accelerator, embolization, and microsurgical resection. Each of these options is better for certain cases, and sometimes a combination of options is best. There are so many ways to customize treatment that doctors will have a hard time using a study that considers all treatments–and all AVMs–the same. So unfortunately, ARUBA’s “data…while sure to be widely quoted, will do little…to meaningfully direct the care of patients,” writes Dr. Solomon.

What to do?

When it comes to treatment for AVMs, doctors must still rely on their education and their extensive experience to decide on the best treatment for each individual patient. This is one reason that AVMs should usually be treated at major medical centers by doctors who have plenty of experience with these complex lesions. Department director Dr. Solomon, for example, has treated nearly a thousand AVMs in his career. Dr. Connolly, Dr. Lavine, and Dr. Meyers, the skilled and experienced surgeons who make up the outstanding Cerebrovascular Center team, have treated hundreds more. ARUBA may be good for keeping things simple, but in the complex case of AVMs, the skill and experience of these surgeons is hard to beat.

Dr. Robert Solomon
Dr. Robert Solomon

Learn more about Dr. Robert Solomon here
Learn more about Columbia’s Cerebrovascular Center here

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