Types of pain associated with vascular malformations

  • Chapter: Pain therapy and anesthesia

    Article: 2 of 8

    Update: Feb 24, 2021

  • Author(s): Kramer, Jens

Various types of pain can occur during the natural course of a vascular malformation and also during the course of treatment. Basically, pain can be classified according to its origin or cause as well as its duration.

Type and cause of pain

Pain is triggered by the excitation of nociceptors in the tissue. These free nerve endings can be stimulated by various stimuli: endogenous chemical stimuli (e.g., prostaglandins, cytokines, etc.), exogenous stimuli (pressure, heat, cold, etc.).

The following types of pain arise, depending on localization and region in the body:

Pain typeDesignation 
Nociceptive painSoft tissue
(connective tissue, muscle,
tendons, ligaments)
  • Dull, pressing
  • Can often be well localized
  • Pain can radiate
 Bone pain
  • Stabbing, piercing
  • Can be well localized
  • Pain peaks with movement
 Visceral pain
  • Cramp-like, diffuse, dull
  • Pain projection
  • Co-reaction of surrounding tissue
  • Reflex muscle tension
Neuropathic painVarious triggers and
sources of damage:
  • Shingles, diabetes mellitus,
    phantom limb pain, et al.
  • Mechanical, inflammatory,
  • Burning continuous pain
  • Electric shock-like/shooting
  • Spreading in the nerve supply area
  • Sensory dysfunction possible
    (abnormal sensations, disturbed sensation
    of cold/heat)

The pain experienced prior to treatment of a vascular malformation can in many cases indicate the underlying nature of the vascular malformation:

MalformationPain triggersSymptom
of venous malformations
Recurrent thrombophlebitis
  • Local swelling and induration
  • Redness, bluish discoloration
 High venous pressure due to
reflux or central stenosis
  • Pressure and tension
    in the lower leg/foot
  • Primarily when
    standing/lengthy sitting
of arteriovenous malformations
AV shunts
with venous hypertension
  • Ischemic pain
  • Wound healing disorders
    in extremities due to
  • Insufficient tissue supply
  • Wound infection

The timing of the onset of pain also plays a role.

Immediately during treatment, intervention/surgery:

  • Direct pain from the puncture and intervention/surgery
  • Pain due to injected drugs
  • Pain due to therapy-induced acute ischemia or inflammation

Post-treatment (postoperative):

  • Wound pain at the onset of wound healing or any inflammatory remodeling processes in the affected tissues

With regard to the development and treatment of chronic pain, not only in the context of vascular malformations, two important descriptions apply: multifactorial and interdisciplinary.

Causes of chronic pain

  • Pain can become chronic  in the context of incorrect therapy or lack of treatment of the malformation or during post-interventional follow-up.
  • Osteoarthritis with permanent pain-induced relieving posture may cause functional impairment in joint-adherent vascular malformations.
  • Chronic wounds, especially in AVM, are particularly painful when an additional infection is present (indicator function).
  • Chronic venous hypertension or chronic venous insufficiency can lead to continuous pain, especially during stress or exercise.
  • The clinical picture of FAVA (fibro-adipose vascular anomaly), in particular, often leads to chronic neuropathic pain that is difficult to treat, probably due to intraneural or perineural encasement of peripheral nerves with the fibrous tissue, in addition to progressive contracture of the affected muscle.
  • Psychosocial factors.
  • etc.

Typical characteristics of chronic pain

  • Long lasting
  • Pain intensity does not necessarily correlate with event and cause
  • Inadequate response to various analgesics
  • Primary or secondary psychological stress situation
  • Reduction in performance
  • Frequent changes of doctor
  • etc.

Measurement of pain intensity

Common methods for quantifying the intensity of pain are a numerical ranking scale (NRS) or the visual analog scale (VAS). These involve visualizing or ranking the pain intensity using symbols (e.g., smiley, color) or numbers, depending on the patient’s age or language barriers.

Scientific measurement of health-related quality of life by means of special questionnaires that patients fill out themselves can also yield quantitative information about pain intensity. One example is the SF-36 Version 2 pain scale, which is available in various translations.