Trapezius hemangioma is actually a high-flow structural complex arteriovenous malformation. I used to introduce complex arteriovenous malformations to my students in my classes in this way: “The limbs of normal people are made by God; the limbs of patients with arteriovenous malformations are made by the devil and are full of unknowns, and the complexity of their lesions is such that even with the most advanced examination tools available, what can be shown is probably only the tip of the iceberg”. From the clinical manifestations, the masses with high flow can be palpated and vascular murmurs can be heard; those with low flow will also show elevated skin temperature, thickened limbs, and vigorous hair growth. If left untreated, the deformity will become more and more serious, the blood flow will become more and more intense, and eventually the whole limb muscle group or even the skeletal system may be destroyed, and only forced to amputate the limb. Therefore, treatment is a must. However, treatment options are at the same time complex and quite risky. There are approximately three treatment options for arteriovenous malformations: Treatment option 1: Endoluminal treatment. Embolization is used to block the outlet or fistula of the arterial branch of the variant, thus achieving treatment. Theoretically, this option should be very effective, but in practice it is easier said than done. The difficulty lies in the fact that such arterial malformations have a considerable number of fistulas and branches. Some of them present as open and are visible on the film. Some of them are normally closed and do not show up on the film at all. Once the other fistulas are closed, these potential fistulas start to open, and in terms of number, the potential fistulas that are normally closed are several times more than the open ones, even uncountable. Therefore, after intraluminal treatment, it may seem that the fistula is blocked, but in fact it is only a small part of it. Within days, or even hours, the potential fistula is completely replaced and the malformed mass remains. Repeated and multiple embolization treatments can also make further surgical procedures difficult. However, this treatment also has the advantage of being less invasive and can be repeated. Treatment option 2: surgical treatment. It is not an exaggeration: even for highly qualified surgeons, surgery for arteriovenous malformations can be a difficult and severe challenge. Not to mention complex arteriovenous malformations, which are basically the nightmare of most surgeons, many surgeons’ operating table careers stop at such procedures, and the lessons learned from rash surgical treatment of arteriovenous malformations are profound, and the examples are endless. However, do not completely despair, there are still some patients who can be treated better with surgery through careful judgment and thorough preparation. This depends on the complexity of the arteriovenous malformation, its extent, its location, the importance of the function of the limb in which it is located, and so on. It is a comprehensive judgment of the advantages and disadvantages, and this judgment is only a treatment preference of the doctor, and whether it becomes the final treatment plan depends on the patient’s understanding and acceptance, as well as the patient’s financial situation, etc. After all, this is a very complex lesion and there is a great deal of uncertainty about the surgery itself. If this cannot be understood, or if the patient is not fully prepared for the consequences of a failed surgery, then it is better not to have the surgery. Treatment option 3: a combination of intracavitary and surgical treatment. Each takes its own strengths and is performed in stages, generally in the order of embolization followed by surgery. In conclusion, the treatment of complex arteriovenous malformations is very difficult. However, the consequences of not treating it are also obvious. Knowing that it is difficult and doing it requires great courage and strength on the part of the surgeon, and enough wisdom on the part of the patient’s family to cooperate and understand. I hope that one day, better tests will be available to make the devil appear, and better treatments will be available to make all young patients smile after a long time.