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Shen Y, Wang D, Fan X, Zheng L, Su L, Yang X. Ethanol embolization of arteriovenous malformations in the buttock: ten-year experiences in diagnoses and treatment options. Orphanet J Rare Dis 2024; 19:195. [PMID: 38741122 DOI: 10.1186/s13023-024-03205-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 05/05/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Clinically, arteriovenous malformations in the buttocks (bAVMs) are extremely rare. Our study aimed to evaluate the efficacy and safety of ethanol embolotherapy in managing bAVMs. RESULTS A total of 32 patients with bAVMs (14 females and 18 males) from 2012 to 2021 were included in this study. All patients underwent complete clinical and imaging examinations. Further, the AVMs lesions were analyzed according to Schöbinger staging and Yakes classification. Each patient had undergone a multistage ethanol embolization. The amelioration of clinical symptoms and devascularization on angiography were evaluated at regular follow-ups. In the present cohort, the 11-20 age group had the most patients (15/32; 46.88%). A total of 124 embolization procedures were performed (average 3.88 procedures per patient), and the average dose of absolute ethanol was 18.96 mL per procedure. Thirteen patients with dominant draining veins underwent additional coil deployment before ethanol embolization (13/32; 40.63%). During follow-ups, clinical improvement was found in 23 of 27 who presented with a pulsating mass (85.19%), 17 of 20 with abnormal local skin temperature (85%), 5 of 6 with bleeding (83.33%), and 5 of 5 patients treated for pain (100%). More than 75% angiographic devascularization was achieved in 18 patients (18/32; 56.25%). Finally, 12 out of 13 patients (92.31%) reduced from Schöbinger Stage III to a lower grade, and ten patients exhibited a complete response (10/32; 31.23%). There was a single serious complication of local necrosis, while neither paranesthesia nor infection was observed postoperatively. CONCLUSIONS Ethanol embolization assisted with coils can treat bAVMs effectively and safely. The Yakes classification contributed to the optimal ethanol embolotherapy of bAVMs.
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Affiliation(s)
- Yuchen Shen
- Vascular Anomaly Center, Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhi Zao Ju Rd, Shanghai, 200011, China
| | - Deming Wang
- Vascular Anomaly Center, Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhi Zao Ju Rd, Shanghai, 200011, China
| | - Xindong Fan
- Vascular Anomaly Center, Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhi Zao Ju Rd, Shanghai, 200011, China
| | - Lianzhou Zheng
- Vascular Anomaly Center, Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhi Zao Ju Rd, Shanghai, 200011, China
| | - Lixin Su
- Fengcheng Hospital of Feng Xian District, Fengcheng Branch, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201413, China.
| | - Xitao Yang
- Vascular Anomaly Center, Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhi Zao Ju Rd, Shanghai, 200011, China.
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See AP, Smith ER. Management of Pediatric Intracranial Arteriovenous Malformations. J Korean Neurosurg Soc 2024; 67:289-298. [PMID: 38433517 PMCID: PMC11079567 DOI: 10.3340/jkns.2024.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
Pediatric intracranial arteriovenous malformations (AVMs) are challenging lesions managed by pediatric neurosurgeons. The high risk of hemorrhage and neurologic injury is compounded by the unique anatomy of each malformation that requires individualizing treatment options. This article reviews the current status of pediatric AVM epidemiology, pathophysiology and clinical care, with a specific focus on the rationale and methodology of surgical resection.
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Affiliation(s)
- Alfred Pokmeng See
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R. Smith
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Holden A, Krauss M, O'Hara R, Jones J, Smith DK. A First-in-Human Trial of a New Aqueous Ionic Liquid Embolic Material in Distal Embolization Applications. J Vasc Interv Radiol 2024; 35:232-240.e1. [PMID: 37931844 DOI: 10.1016/j.jvir.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/12/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE A prospective, single-arm, open-label, multicenter, first-in-human, early feasibility study was completed to evaluate the safety and performance of the GPX Embolic Device (Fluidx, Salt Lake City, Utah), a novel liquid embolic agent, for use in the peripheral vasculature when deep distal embolization is desired. MATERIALS AND METHODS The early feasibility study evaluated the use of the device in the peripheral vasculature. Enrollment consisted of 17 patients with diverse embolization needs requiring deep distal vessel/vessel bed occlusion. Technical success, freedom from adverse events (AEs), and handling/performance characteristics were assessed with follow-up at 30 days. RESULTS The trial enrolled 17 patients requiring distal vascular penetration of the embolic agent, including 7 with renal angiomyolipomas, 4 with renal cell carcinomas (primary and secondary), 4 with portal veins needing embolization, 1 with pelvic sarcoma, and 1 with polycystic kidney. In all cases (100%), technical success was achieved with target regions fully occluded on the first angiogram (taken immediately after delivery). Furthermore, the material received high usability ratings, as measured by a postprocedural investigator questionnaire. Most patients (15/17, 88.2%) were free from device-related severe AEs, and there were no unanticipated AEs during the study. Each patient completed a 30-day follow-up evaluation, and sites remained fully occluded in each case where imaging was available (6 [35.3%] of 17 patients had follow-up imaging where all sites were deemed occluded [100%] with a mean of 30.2 days after the procedure). CONCLUSIONS The results of this first-in-human, early feasibility study demonstrate that the GPX Embolic Device may provide safe and effective embolization for arterial or venous applications where deep distal penetration is desired.
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Affiliation(s)
- Andrew Holden
- Auckland City Hospital, School of Medicine, University of Auckland, Auckland, New Zealand.
| | - Martin Krauss
- Christchurch Hospital, University of Otago, Christchurch Central City, South Island, New Zealand
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Nico E, Hossa J, McGuire LS, Alaraj A. Rupture-Risk Stratifying Patients with Cerebral Arteriovenous Malformations Using Quantitative Hemodynamic Flow Measurements. World Neurosurg 2023; 179:68-76. [PMID: 37597662 DOI: 10.1016/j.wneu.2023.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
Arteriovenous malformations (AVMs) are high-pressure, low-resistance arterial-venous shunts without intervening capillaries. Up to 60% of AVMs present with an intracranial hemorrhage; however, noninvasive neuroimaging has increasingly diagnosed incidental AVMs. AVM management depends on weighing the lifetime rupture risk against the risks of intervention. Although AVM rupture risk relies primarily on angioarchitectural features, measuring hemodynamic flow is gaining traction. Accurate understanding of AVM hemodynamic flow parameters will help endovascular neurosurgeons and interventional neuroradiologists stratify patients by rupture risk and select treatment plans. This review examines various neuroimaging modalities and their capabilities to quantify AVM flow, as well as the relationship between AVM flow and rupture risk. Quantitative hemodynamic studies on the relationship between AVM flow and rupture risk have not reached a clear consensus; however, the preponderance of data suggests that higher arterial inflow and lower venous outflow in the AVM nidus contribute to increased hemorrhagic risk. Future studies should consider using larger sample sizes and standardized definitions of hemodynamic parameters to reach a consensus. In the meantime, classic angioarchitectural features may be more strongly correlated with AVM rupture than the amount of blood flow.
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Affiliation(s)
- Elsa Nico
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Jessica Hossa
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois Hospital, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois Hospital, Chicago, Illinois, USA.
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Tanoue S, Tanaka N, Koganemaru M, Kuhara A, Kugiyama T, Sawano M, Abe T. Head and Neck Arteriovenous Malformations: Clinical Manifestations and Endovascular Treatments. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2023; 8:23-35. [PMID: 37485489 PMCID: PMC10359175 DOI: 10.22575/interventionalradiology.2022-0009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/01/2022] [Indexed: 07/25/2023]
Abstract
Arteriovenous malformations (AVMs) are vascular malformations that present high-flow direct communication between the arteries and veins, not involving the capillary beds. They can be progressive and lead to various manifestations, including abnormal skin or mucosal findings, ischemia, hemorrhage, and high-output heart failure in severe cases. AVMs often involve the head and neck region. Head and neck AVMs can present region-specific clinical manifestations, angioarchitecture, and complications, especially in cosmetic appearance and ingestion, respiratory, and neuronal functions. Therefore, when planning endovascular treatment of head and neck AVMs, physicians should consider not only the treatment strategy but also the preservation of the cosmetic appearance and critical functions. Knowledge of the functional vascular anatomy as well as treatment techniques should facilitate a successful management. This review summarizes AVMs' clinical manifestations, imaging findings, treatment strategy, and complications.
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Affiliation(s)
- Shuichi Tanoue
- Department of Radiology, Kurume University School of Medicine, Japan
| | - Norimitsu Tanaka
- Department of Radiology, Kurume University School of Medicine, Japan
| | | | - Asako Kuhara
- Department of Radiology, Kurume University School of Medicine, Japan
| | - Tomoko Kugiyama
- Department of Radiology, Kurume University School of Medicine, Japan
| | - Miyuki Sawano
- Department of Radiology, Kurume University School of Medicine, Japan
| | - Toshi Abe
- Department of Radiology, Kurume University School of Medicine, Japan
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Behzadi F, Heiferman DM, Wozniak A, Africk B, Ballard M, Chazaro J, Zsigray B, Reynolds M, Anderson DE, Serrone JC. Comparison of transarterial n-BCA and Onyx embolization of brain arteriovenous malformations: A single-center 18-year retrospective analysis. J Cerebrovasc Endovasc Neurosurg 2022; 24:144-153. [PMID: 35526856 PMCID: PMC9260459 DOI: 10.7461/jcen.2022.e2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/02/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Brain arteriovenous malformations (AVM) are commonly treated with endovascular embolization. Due to the rapid evolution of endovascular technology and lack of consistent practice guidelines regarding AVM embolization, further study of AVM embolization outcomes is warranted. METHODS We conducted a retrospective review of AVMs embolized at a single center from 2002-2019. Patient demographics, AVM characteristics, intention of embolization, and angiographic and clinical outcome after embolization were recorded. We compared the embolization results of those treated with n-butyl cyanoacrylate (n-BCA) and Onyx. RESULTS Over an 18-year period at our institution, 30 (33%) of 92 AVMs were treated with embolization. n-BCA was used in 12 cases and Onyx in 18 cases. Eighty-seven pedicles were embolized over 47 embolization sessions. Fifty percent of AVMs treated with n-BCA underwent more than one embolization session compared to 22% when Onyx was used. The median total percent volume reduction in the n-BCA AVMs was 52% compared to 51% in Onyx AVMs. There were 2 periprocedural complications in the n-BCA cohort and none in the Onyx cohort. CONCLUSIONS In this small retrospective series, Onyx and n-BCA achieved similar occlusion results, although n-BCA required more sessions and pedicles embolized to do so.
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Affiliation(s)
- Faraz Behzadi
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | | | - Amy Wozniak
- Clinical Research Office, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Benjamin Africk
- Department of Pediatric Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew Ballard
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Joshua Chazaro
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Brandon Zsigray
- Department of Neurological Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Matthew Reynolds
- Department of Neurological Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Douglas E Anderson
- Department of Neurological Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Joseph C Serrone
- Department of Neurological Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
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A Rational Approach to the Management of Cerebral Arteriovenous Malformations. World Neurosurg 2022; 159:338-347. [DOI: 10.1016/j.wneu.2021.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 11/21/2022]
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Pan P, Weinsheimer S, Cooke D, Winkler E, Abla A, Kim H, Su H. Review of treatment and therapeutic targets in brain arteriovenous malformation. J Cereb Blood Flow Metab 2021; 41:3141-3156. [PMID: 34162280 PMCID: PMC8669284 DOI: 10.1177/0271678x211026771] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/23/2022]
Abstract
Brain arteriovenous malformations (bAVM) are an important cause of intracranial hemorrhage (ICH), especially in younger patients. The pathogenesis of bAVM are largely unknown. Current understanding of bAVM etiology is based on studying genetic syndromes, animal models, and surgically resected specimens from patients. The identification of activating somatic mutations in the Kirsten rat sarcoma viral oncogene homologue (KRAS) gene and other mitogen-activated protein kinase (MAPK) pathway genes has opened up new avenues for bAVM study, leading to a paradigm shift to search for somatic, de novo mutations in sporadic bAVMs instead of focusing on inherited genetic mutations. Through the development of new models and understanding of pathways involved in maintaining normal vascular structure and functions, promising therapeutic targets have been identified and safety and efficacy studies are underway in animal models and in patients. The goal of this paper is to provide a thorough review or current diagnostic and treatment tools, known genes and key pathways involved in bAVM pathogenesis to summarize current treatment options and potential therapeutic targets uncovered by recent discoveries.
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Affiliation(s)
- Peipei Pan
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
| | - Shantel Weinsheimer
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
| | - Daniel Cooke
- Department of Radiology, University of California, San Francisco, USA
| | - Ethan Winkler
- Department of Neurosurgery, University of California, San Francisco, USA
| | - Adib Abla
- Department of Neurosurgery, University of California, San Francisco, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
| | - Hua Su
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, USA
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Glue, Onyx, Squid or PHIL? Liquid Embolic Agents for the Embolization of Cerebral Arteriovenous Malformations and Dural Arteriovenous Fistulas. Clin Neuroradiol 2021; 32:25-38. [PMID: 34324005 PMCID: PMC8894162 DOI: 10.1007/s00062-021-01066-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/01/2021] [Indexed: 12/29/2022]
Abstract
Background Endovascular embolization is an effective treatment option for cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs). A variety of liquid embolic agents have been and are currently used for embolization of AVMs and DAVFs. Knowledge of the special properties of the agent which is used is crucial for an effective and safe embolization procedure. Material and Methods This article describes the properties and indications of the liquid embolic agents which are currently available: cyanoacrylates (also called glues), and the copolymers Onyx, Squid and PHIL, as well as their respective subtypes. Results Cyanoacrylates were the predominantly used agents in the 1980s and 1990s. They are currently still used in specific situations, for example for the occlusion of macro-shunts, for the pressure cooker technique or in cases in which microcatheters are used that are not compatible with dimethyl-sulfoxide. The first broadly used copolymer-based embolic agent Onyx benefits from a large amount of available experience and data, which demonstrated its safety and efficacy in the treatment of cerebral vascular malformations, while its drawbacks include temporary loss of visibility during longer injections and artifacts in cross-sectional imaging. The more recently introduced agents Squid and PHIL aim to overcome these shortcomings and to improve the success rate of endovascular embolization. Novelties of these newer agents with potential advantages include extra-low viscosity versions, more stable visibility, and a lower degree of imaging artifacts. Conclusion All the available liquid embolic agents feature specific potential advantages and disadvantages over each other. The choice of the most appropriate embolic agent must be made based on the specific material characteristics of the agent, related to the specific anatomical characteristics of the target pathology.
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