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ENDOVASCULAR MANAGEMENT OF COMPLEX VASCULAR
MALFORMATIONS
Prof. Furuzan Numan, M.D
Chief of Interventional Radiology Department
Istanbul University
Cerrahpasa School of Medicine
ISTANBUL,TURKEY 2013 ASVS&ASVF
VMs
• Arterio-venous malformations (AVMs) (CVMs)• birth defects which involve the arterial and venous
vessels ,• direct communications between the different size
vessels• dysplastic minute vessels( a meshwork of primitive
reticular networks) which have failed to mature to become 'capillary'
• Create the ”NIDUS".
VMs
• Shunting through the fistulous structures(AVF)
with high velocity, low resistance flow from
the arterial vasculature into the venous system.• AVFs result in significant anatomical,
pathophysiological and hemodynamic consequences.
VMs
• Systematic classifications such as (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs)
• help us to understand the biology and natural history of these lesions and improved management.
Modified Hamburg Classification
Updated ISSVA Classification
DIAGNOSIS
• Duplex ultrasound,CDUS,• Magnetic resonance imaging (MRI), • MR angiography (MRA), • Computerized tomography (CT) and• CT angiography (CTA).
DIAGNOSIS
• Arteriography (DSA) is the gold standard for • diagnosis , • treatment
VMs
• A multidisciplinary team is necessary to integrate surgical and non-surgical interventions for optimum care.
TREATMENT
• Surgery ?• Endovascular?
INDICATIONS of ENDOVASCULARTREATMENT
• congestive heart failure at high flow VM’s having AVF components results of previous surgery/s or diagnostic biyopsy.
• relief the pain• functional disorders of extremities and joints• cosmetic problems
VM’s
Ideal embolic agent should be; • easily controlled during injection• able to penetrate & occlude the abnormal
foci(nidus) of vascular communications in VM’s
• provide permanent occlusion
VMs
An IDEAL EMBOLIC AGENT should match MORPHOLOGY & HEMODYNAMIC status of VMs
Structure of the Nidus
WHICH EMBOLIC AGENT IS IDEAL?
Detachable Coils,
Amplatzer Plugs,
Polyvinilalcohol(PVA),
Ethanol,
N-ButrylCyanoacrylate( Glue),
Onyx
DETACHABLE COILS ,AMPLATZER PLUG
• Proximal occlusion of the VM’s• No penetration to the foci• prevent future endovascular access to the
lesions via the arterial route
VM’s
VM’s
PVA;• Difficult to determine appropriate size • Have risk of pulmonary embolism• Usually arrested at precapillary level• Recanalized after 2-3 weeks
VM’s ETHANOL;• Direct toxic effect on endothelium causes
coagulation & thrombosis• Non-target embolization may occur via
transcatheter use• Nerve damage
Disadvantage of large amounts of ethanol causes;• CNS depression• Hemolysis• Cardiac arrest
VM’s Acrylic polymers (N-BCA) (GLUE)
Polymerizes with blood or other ionic fluids• Causes exothermic reaction• Destroys vessel wall
Disadvantages due to rapid polymerization;• Precise & safe occlusion is difficult• High risk of adhesion of the microcatheter to the
vessel wall• Microcatheter is out of use after each injection
ONYX
Biocompatible liquid embolic agent consists of;
• ETHYLENE VINYL ALCOHOL COPOLYMER dissolved in various concentrations of DIMETHYL SULFOXIDE (DMSO)
• TANTALUM powder
ONYX DMSO causes in situ;
• PRECIPITATION & SOLIDIFICATION of the polymer forms the
ELASTIC SPONGY EMBOLUS has NO ADHESIVE effect to the wall
BARDeV3
ONYX Injection technique
• Co-axial system:Catheter(4F), microcatheter & microguidewire
ev3 Inc- Confidential Information CR00031 Jun/08
Onyx Delivery Systems
Marathon
And
UltraFlow
Flow-directed Microcatheters
Rebar
Microcatheters
Mirage,
X-pedion, SilverSpeed
Guidewires
ONYX injection ( Plug and Push )technique
• Flushing microcatheter with saline solution is required• 0.4 ml dead space of microcatheter should be filled with
DMSO• 1 ml ONYX aspirated into syringe• 0.25 ml of the amount injected during 40 seconds until
to fill & replace DMSO in the microcatheter• ONYX was injected at a volume & rate enough to
prevent reflux but cause enough penetration as distally as possible under fluoroscopic guidance
At modified injection technique
• ONYX to penetrate more distally than microcatheter had riched,
• and makes to use the microcatheter(and macrocatheter) more than once which saves time & money
• rare gluing to the arterial wall• longer injection time & more controlled embolization • per-embolization angiography can be performed with
the same microcatheter• Minimizing the reflux
Flushing microcatheter lumen with DMSO helps;
COMPLICATIONS
• DMSO related vasospasm • main artery occlusion• bullous form of skin burns due to non-target
embolization • microcatheter tip adhesion• pulmonary embolism• venous reflux
Skin burns result
of non-target embolization
THE REASON of REFLUX & NON-TARGET
EMBOLIZATION • inefficiency of the test injection due to viscosity
differences between Onyx & contrast media• complex and unpredictable angiostructure of VMs • short arterial feeders close to the parent arteries • poor radioopacity due to concentration
MANEUVERS to prevent REFLUX in high-flow VMs
• external compression to stagnate the flow• use of high concentration of copolymer• controlled and slow injection
DISADVANTAGES
• GENERAL ANESTHESIA procedure is painful
• DMSO cause the PAIN
• GARLIC LIKE smell of breath
• PRICE
• NEED OF EXTRA SESSIONS
37/F R Shoulder,pain swelling
32 year old man,suffers upper left chest mass&limitation of effort
27 y Female Left upper extremity surgery.Pain, swelling, varicosity, discoloration, thrill, congestive heart failure
MR Color-Doppler US
30 y female, Previous surgery, High-flow VM of the right forearm
Right upper extremity ,forearm AVM31 y,Female
S.A. 33-years-old male, right gluteal local VM. Pain, limitation of movement, swollen of the extremity with effort.
Pre-embolization Post-embolization
18-y Male, right gluteal local low-flow VMPain, swelling & varicosity
Pre-embolization Post-embolization
Acute Bleeding of Uterine AVM
23 year old female
Acute Bleeding of Uterine AVM
23 year old female
Right upper extremity diffuseHemangioma21 y Male
Right lower extremity diffuseHemangioma,between age of 16-20 ,Female 3 sessions
AVM,18y FemalePreviously embolizedLocation: basis of left foot, metacarpal areaOrigin: Lateral and medial plantar branches of posterior tibial artery
NOTES TO TAKE HOME
• Do not take the chance of being treated endovascularly from these desparate patients,
• by using Amplatz Plugs,Coils ,
• ligating main(feeding)arteries surgicaly