Arteriovenous Malformations

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Postgraduate Course Venous Endovascular Course
Directors Scott L. Stevens, M.D. Mark A.
Farber, M.D.
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Introduction Kim Hansen, MD WFU School of
Medicine Winston-Salem, NC
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Arteriovenous Malformations.

• Alan B. Lumsden, Chairman Cardiovascular Surgery
  
• Houston, Texas

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Vascular Lesion Treatment

• Arteriovenous Malformation (AVM)
• Definition - Congenital lesion

Abnormal arteriovenous communications Feeding
arteries Nidus Outflow veins
Symptoms Significant shunting / CV
compromise Pain, neuromuscular dysfunction,
tissue ulceration Hemorrhage
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Treatment

• Absolute indications
• Hemorrhage
• Ischemia (steal)
• Refractory ulceration
• Congestive heart failure
• Relative indications
• Disabling pain
• Claudication
• Functional impairment

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Treatment

• Conservative
• Stockings
• Limb elevation
• Surgery
• 10 lesions
• Best after embolization
• 100 success when amenable for resection

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Vascular Lesion Treatment

• AVM Embolization
• Effective therapy

Destruction of the nidus
Procedural requirements Superselective access
to feeding artery Injection non-resorbable
embolic agent into the nidus
Contour PVA particles / Contour-SE microspheres
Absolute ethanol n-BCA .014/.035 Coils
(Vortx-18 or Vortx-35)
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Present understanding phases vascular
development.
Embryology Stage I Undifferentiated
primitive blood lakes, capillary networks, no
veins or arteries Stage II Retiform Capillaries
form large plexiform structures Stage III
Maturation Mature vascular channels
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MRI Classification
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What do we really need to know?

• Location
• subcutaneous
• deep to fascia
• both
• Proximity to major structures
• sciatic nerve
• rectum
• Localized or diffuse
• Arterial or venous
• relative contribution

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towel roll
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head
foot
rectus femoris
femoral nerve branches
tensor fascia lata
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venous connection
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joint capsule
femur
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Treatment

• Embolization
• Multiple sessions
• Long-term commitment
• Usually under general anesthesia
• Some report 79 success with 20 complications

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Steps for safe embolization

• Good preliminary angiography
• Think about collateral pathways
• Use shortest straightest approach, especially
  when coils used
• Stable catheter position and verify
• Wire if using coils
• Contrast if soluble agent
• Use non-heparinized saline to flush and dilute
  contrast
• Continuous fluoro during embolization
• Intermittent runs to evaluate flow

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Vascular Lesion Treatment
AVM Embolization Hazards Non-Target Distal
embolic embolization
Prevention Proper sizing of PVA microspheres /
particles Impact within the nidus
Careful injection of liquid embolics Contain
effects within nidus
Proper sizing of coils Reduce risk of displacement
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Non-resorbable Embolic Agents Liquid Embolic
Agent
n-Butyl Cyanoacrylate (n-BCA) Description Tissue
adhesive or glue Treatment of cerebral AVMs
Mechanism of action Polymerization upon contact
with ionic fluids Formation of a solid cast
within the vessel Vessel occlusion

• Technique
• Coaxial delivery
• Flushing with non-ionic dextrose solution
• Immediate catheter withdrawal

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• AVM dorsum left hand
• Draining vein punctured
• Tourniquet above arterial pressure
• 2.5cc absolute ETOH via 3Fr catheter

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• Radial Head AVM, multiple vessels feeding venous
  component.
• Catheter inserted into draining vein.
• Absolute alcohol injected in 4 stages.
• Venogram at 6 months - ablation of veins

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Early Polymerization

• TRUFILL n-BCA mixture solidifies
• In the microcatheter - catheter occlusion
• In the AVM before the desired depth of
  penetration within a feeding pedicle
• At the microcatheter tip
• n-BCA adherent to tip at risk for embolus
• n-BCA adherent to tip at risk for catheter
  retention

• Reflux, polymerization of non-target vessel
• Complications
• Ischemia
• AVM or vessel rupture

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Conclusion AVM Treatment

• These patients lack a home
• Vascular Surgeons see most of AVM,s
• No single therapeutic option
• Need broad oversight
• Emerging advanced endovascular skills in
  vascular surgery community
• Rapid growth of excellent imaging
• MEN -1 of vascular surgery patient for life
• Research- clinical- teaching opportunities

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TRUFILL Tantalum Powder

• Finely ground, irregularly shaped, dark gray
  metal
• Used with TRUFILL Ethiodized Oil to radiopacify
  TRUFILL n-BCA liquid embolic agent
• Mix tantalum with TRUFILL Ethiodized Oil prior
  to mixing with TRUFILL n-BCA
• DO NOT use TRUFILL Tantalum Powder alone as a
  radiopacifying agent for n-BCA

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TRUFILL Ethiodized Oil

• Straw to amber colored oily fluid
• Contains 37 iodine organically combined w/
  poppyseed oils ethyl esters of fatty acids
• Injectable, radiopaque agent to be used with
  n-BCA Liquid Embolic System to control
  polymerization
• DO NOT use TRUFILL Ethiodized Oil alone as a
  diagnostic agent

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TRUFILL n-BCA Procedure Set-up

• Inject TRUFILL Ethiodized Oil
• into sterile beaker

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TRUFILL n-BCA Procedure Set-up

• Add TRUFILL Tantalum Powder
• to sterile beaker

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TRUFILL n-BCA Procedure Set-up

• Mix TRUFILL Ethiodized Oil
• and TRUFILL Tantalum Powder

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TRUFILL n-BCA Procedure Set-up

• Attach self-piercing cap to the syringe
• then attach to the TRUFILL n-BCA vial

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TRUFILL n-BCA Procedure Set-up

• Aspirate TRUFILL n-BCA into syringe

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TRUFILL n-BCA Procedure Set-up

• Add TRUFILL n-BCA to mixture in beaker
• and mix thoroughly

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TRUFILL n-BCA Procedure Set-up

• Rinse microcatheter hub with syringe of D5W

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TRUFILL n-BCA Procedure Set-up

• Flush microcatheter with D5W

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TRUFILL n-BCA Procedure Set-up

• Aspirate TRUFILL n-BCA mixture into syringe
• Compare mixture-filled syringe with
  contrast-filled syringe
• under fluoroscopy

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TRUFILL n-BCA Procedure Set-up

• Inject TRUFILL n-BCA mixture through microcatheter

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 Microcatheters

• TRUFILL n-BCA is compatible with
• PROWLER Microcatheter family.
• PROWLER SELECT Microcatheter family.
• TRANSIT Microcatheter family
• RAPIDTRANSIT Infusion catheter
• MASSTRANSIT Max ID catheter
• TRANSIT Microcatheter