This goal is remarkable because arteriovenous malformations are among the most complex problems a neurosurgeon can treat.
For some patients, surgery is the best option. Unfortunately, it would be almost impossible to know that by looking at the ARUBA study results. ARUBA seems to indicate that the risks of surgery outweigh the benefits.
This is a situation where the famous complexity of AVMs has not been accounted for. Some AVMs are low-risk for surgery. This means that the probable benefit of surgery far outweighs the probable risk of simply waiting and observing the lesion. These are classified as Grade 1 or Grade 2 AVMs. But in the ARUBA study, a significant number of the patients whose AVMs were treated had higher-grade AVMs. Classified as Grade 3 or Grade 4, these AVMs present a less clear-cut treatment picture.
So in ARUBA, data from low-risk patients was lumped in together with data from higher-risk patients. The result is that treatment looks riskier than it is for some patients. “The ARUBA error,” says Dr. Solomon, is that the “results are not reflective of surgical outcomes for properly selected patients.” That is, for patients who are likely to do well with surgery.
To drive home his point, Dr. Solomon presented a summary of papers published over the last three decades. Together, the papers include more than 1200 low-grade AVMs. Problems due to surgery occurred in only 2.5% of patients, and the surgical cure rate was 98.5%.
Then Dr. Solomon presented his own data, a series of more than 200 of his surgeries on low- and medium-grade AVMs. For his patients with low-grade AVMs, 99.4% were cured with surgery. But surgery also cured 97% of the riskier Grade 3 patients that he operated on.
This is due not just to Dr. Solomon’s surgical skill, but also to his skill and experience at determining which Grade 3 patients might be good candidates for surgical treatment. “Selected Grade 3 patients can do well with surgery,” he says. It’s all a matter of weighing the complexities of each individual case.
And it’s exactly because of these complexities that nothing can replace the skill and experience of an AVM expert.
As Dr. Solomon explains, “young, healthy patients with Grade 1 and 2 AVMs are best treated with microsurgery at regional centers of excellence” like Columbia University Medical Center/NewYork-Presbyterian Hospital. Not only do Dr. Solomon and fellow AVM specialists Dr. E. Sander Connolly, Dr. Sean Lavine, and Dr. Philip Meyers have the necessary surgical skill and surgical experience, they also have the clinical experience to make sure that the treatment plan selected fits each individual patient.
And for a complex topic, that’s as straightforward as it gets.
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