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 type	Designation
Nociceptive pain	Soft 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 pain	Various triggers and sources of damage: Shingles, diabetes mellitus, phantom limb pain, et al. Mechanical, inflammatory, metabolic	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:

Malformation	Pain triggers	Symptom
Venous Symptoms 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
Arteriovenous Symptoms 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.