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