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Ierardi AM, Hohenstatt S, Caranci F, Lanza C, Carriero S, Vollherbst DF, Möhlenbruch MA, Carrafiello G, Paolucci A. Pressure cooker technique in cerebral AVMs and DAVFs: different treatment strategies. LA RADIOLOGIA MEDICA 2023; 128:372-380. [PMID: 36800113 DOI: 10.1007/s11547-023-01605-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 01/31/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND The pressure cooker technique (PCT) was developed to enable safer and more extensive embolization of hypervascular lesions by simultaneously minimizing backflow of liquid embolic materials and thus reduce the risk of non-target embolization of adjacent healthy vessels. We report our experience in applying the PCT to cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) and additionally suggest our technical adjustments. METHODS We retrospectively reviewed all patients suffering from AVMs or DAVFs that were treated with the PCT between 2018 and 2020 in two university hospitals. The endpoints of the study were clinical safety and the technical efficacy. The endpoints of the study were clinical safety and the technical efficacy. Clinical safety was the absence of death, major or minor symptomatic stroke, TIA and procedure-related intracranial bleeding (SAH) in the peri-procedural period until dismission. Good clinical outcome was defined as no deterioration of the modified Rankin Scale (mRS) score (comparing the pre- and post-procedural mRS evaluated by a trained neurologist at admission and dismission). The technical efficacy was considered as the complete embolization occlusion of the target vessels of the lesion documented on the final control angiogram. Long-term follow-up evaluation was not intended for this study as it was not available for all patients. RESULTS Fifteen consecutive patients (6 women; mean age 55 y; range 20-82 y) with seven AVMs and eight DAVFs met the inclusion criteria. The primary clinical safety end point was obtained in all cases as no intraprocedural complications were encountered. All patients had a good clinical outcome with no difference between the pre- and post-mRS scores. The primary efficacy end point was reached in all cases. CONCLUSION The PCT is a safe and effective technique in the treatment of cerebral AVMs and DAVFs. Adding an easy and fast step to the procedure, namely the injection of contrast media to test the complete obstruction by the plug, the risk of reflux seems to additionally be reduced.
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Affiliation(s)
- Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Sophia Hohenstatt
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ferdinando Caranci
- Department of Diagnostic Radiology and Radiotherapy, Federico II University of Naples, Naples, Italy
| | - Carolina Lanza
- Postgraduate School of Radiology, University of Milan, Milan, Italy
| | - Serena Carriero
- Postgraduate School of Radiology, University of Milan, Milan, Italy
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gianpaolo Carrafiello
- Radiology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Aldo Paolucci
- Neuroradiology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Walker GB, Wang AP, Hadwen J, Erdenebold UE, Bebedjian R, Sullivan P, Santos MP, Chenier C, Karwaski S, Caron K, Varga G, Lyon J, Lesiuk HJ, Heran N, Heran M, Quateen A, Drake BJ, Oliveira EPD, Kontolemos M, Fahed R. Direct Puncture of the Superficial Temporal Artery in Embolization of a Scalp Arteriovenous Fistula: A Case Report. Neurointervention 2023; 18:67-71. [PMID: 36717084 PMCID: PMC9986351 DOI: 10.5469/neuroint.2022.00465] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/16/2023] [Indexed: 02/01/2023] Open
Abstract
We describe a minimally invasive endovascular approach to treat an arteriovenous fistula of the scalp. We performed a direct puncture of the lesion through the patient's scalp for liquid embolic agent injection along with external compression of the superficial temporal artery to perform a "manual pressure-cooker technique." The combination of these minimally invasive techniques resulted in an excellent clinical and radiographic outcome.
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Affiliation(s)
- Gregory B Walker
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Alick P Wang
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jeremiah Hadwen
- Division of Neurology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Undrakh-Erdene Erdenebold
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Razmik Bebedjian
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Patrick Sullivan
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Marlise P Santos
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Division of Radiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Chad Chenier
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Stephen Karwaski
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Katie Caron
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Gabriella Varga
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Lyon
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Howard J Lesiuk
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Navraj Heran
- Division of Neurosurgery, Department of Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada
| | - Manraj Heran
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Aiman Quateen
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Division of Radiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Brian J Drake
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Eduardo Portela De Oliveira
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Division of Radiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Mario Kontolemos
- Division of Radiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Robert Fahed
- Division of Interventional Neuroradiology, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Division of Neurology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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3
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Gölitz P, Luecking H, Knott M, Hock S, Brandner S, Knossalla F, Doerfler A. Microcatheters with extra-long detachable tip: A promising treatment option in dural arteriovenous fistulas. Interv Neuroradiol 2022:15910199221130236. [PMID: 36184923 DOI: 10.1177/15910199221130236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Treating cerebral dural arteriovenous fistulas (dAVFs) by transarterial embolization is an established endovascular approach but no data exist regarding the utility of using the newly introduced microcatheters with extra-long detachable tip. Aim of our study was to evaluate the value of these microcatheters and, additionally, of combining them with the simplified pressure cooker technique. METHODS Twenty-nine patients treated for dAVF with transarterial embolization were enrolled. In a subgroup of fifteen patients the simplified pressure cooker technique was additionally applied. Demographics and characteristics were collected for patients and dAVFs and procedural details reviewed. The association between covariates and binary-coded occlusion status was evaluated. RESULTS Microcatheter navigation into the target pedicle as well as application of the simplified pressure cooker technique were successful in all cases. Complete dAVF occlusion was reached in 69.0% at a single stage. In case of complete dAVF occlusion, embolization via only one pedicle was enough. Subgroup analysis revealed a higher occlusion status (80%) if using the simplified pressure cooker technique than if not (57%) but reached not significance level. CONCLUSION Using microcatheters with extra-long detachable tip for dAVF embolization seems to offer a safe and effective treatment option with exceptional high occlusion rate at a single stage. The high navigability facilitates catheterization of a single selected target pedicle that is often enough to reach complete dAVF occlusion. Combining these microcatheters with the simplified pressure cooker technique turned out to be safe and easy to handle and might allow an increasing dAVF occlusion rate.
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Affiliation(s)
- Philipp Gölitz
- Department of Neuroradiology, 9171Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hannes Luecking
- Department of Neuroradiology, 9171Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, 9171Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Hock
- Department of Neuroradiology, 9171Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Brandner
- Department of Neurosurgery, 9171Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Frauke Knossalla
- Department of Neurology, 9171Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, 9171Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Chen X, Zhang L, Zhu H, Wang Y, Fan L, Ni L, Dong L, Lv M, Liu P. Transvenous embolization of hemorrhagic brain arteriovenous malformations: Case reports and literature review. Front Neurol 2022; 13:813207. [PMID: 36071902 PMCID: PMC9443662 DOI: 10.3389/fneur.2022.813207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 07/12/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Transvenous embolization (TVE) has been proven to be safe and feasible as an alternative management of brain arteriovenous malformations (AVMs). We presented four patients with a hemorrhagic brain AVM who underwent TVE and reviewed the relevant literature. Methods Four patients underwent TVE of a hemorrhagic brain AVM in our center between July 2019 and July 2020. We retrospectively collected and analyzed the clinical and imaging data of these patients and those reported in previously published studies. Results Four patients with a hemorrhagic brain AVM were included. Nidus sizes ranged from 0.79 to 2.56 cm. Spetzler-Martin grade ranged from grade II to grade III. The AVM nidus was located in a deep brain region in three patients. One patient underwent TVE alone and three underwent combined transarterial and transvenous approaches. Digital subtraction angiography (DSA) demonstrated complete obliteration of the vascular malformation after embolization in all four patients. Three patients were independent [modified Rankin Scale (mRS) score ≤ 2] at discharge. All four patients were independent at the last follow-up. AVM obliteration was confirmed in all four patients at the last angiographic follow-up. Conclusion Transvenous embolization can be used as an alternative treatment for contemporary management of brain AVMs, appropriate patient selection is essential to achieve a good clinical outcome.
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Affiliation(s)
- Xiheng Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Longhui Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haoyu Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yajie Wang
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Liwei Fan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leying Ni
- Department of Rehabilitation Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Linggen Dong
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Ming Lv
| | - Peng Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Peng Liu
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5
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He Y, Bai W, Xu B, Kang X, Xue J, He Y, Li T. Perioperative Complications of Transvenous Embolization of Ruptured Intracranial Arteriovenous Malformations. Front Neurol 2022; 13:873186. [PMID: 35432177 PMCID: PMC9009503 DOI: 10.3389/fneur.2022.873186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeTo investigate the perioperative complications of transvenous embolization of ruptured intracranial arteriovenous malformations.Materials and MethodsA total of 27 patients with ruptured intracranial arteriovenous malformations underwent transvenous embolization were enrolled from November 2016 to May 2020 in our prospective database. Perioperative complications and angiographic characteristics were analyzed retrospectively.ResultsComplete disappearance of the nidus occured in 22 (88%) of 25 patients with technically feasible AVMs immediately after embolization. Two cases were partially treated by transarterial embolization due to the failure of microcatheter placement into the draining vein. Seven (25.9%, 7/27) patients had perioperative complications, including three cases of intraoperative hemorrhage, three cases of postoperative hemorrhage and one case of ischemic infarction. No significant differences in complication rates between patients with nidus ≥3 cm and <3 cm (P = 0.659), eloquent area and non-eloquent (P = 0.137), deep location and superficial (P = 0.637), deep venous drainage and cortical vein (P = 1.0), the number of venous drainage (P = 0.49), the angle of draining vein entering venous sinus <90° and ≥90° (P = 1.0), aneurysms (P = 0.058) and the time between hemorrhage and TVE (P = 1.0) were found. Three of these patients received ventriculostomy, two of which received lumbar drainage treatments at the same time, and four patients just received conservative management. Good outcomes (mRS ≤ 2) at the 1-month evaluation were achieved in 5 of the patients who had complications, but poor outcome (mRS = 5) at the 1-month evaluation was in 1 patient, and 1 lethal complication occurred.ConclusionThe most common complication of AVMs with transvenous endovascular embolization is cerebral hemorrhage. The prevention of complications may improve the efficacy of AVM embolization, but the current quality of evidence is low and limited in guiding policy development and improving the TVE for AVMs. It is, therefore, necessary to develop clinical research programs in this field.
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Affiliation(s)
- Yanyan He
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Weixing Bai
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- Weixing Bai
| | - Bin Xu
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Xiaoyu Kang
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Jiangyu Xue
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Yingkun He
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- *Correspondence: Yingkun He
| | - Tianxiao Li
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
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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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Bhatia KD, Lee H, Kortman H, Klostranec J, Guest W, Wälchli T, Radovanovic I, Krings T, Pereira VM. Endovascular Management of Intracranial Dural AVFs: Principles. AJNR Am J Neuroradiol 2022; 43:160-166. [PMID: 34674996 PMCID: PMC8985683 DOI: 10.3174/ajnr.a7304] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
Intracranial dural AVFs are abnormal communications between arteries that supply the dura mater and draining cortical veins or venous sinuses. They are believed to form as a response to venous insults such as thrombosis, trauma, or infection. Classification and management are dependent on the presence of drainage/reflux into cortical veins because such drainage markedly elevates the risk of hemorrhage or venous congestion, resulting in neurologic deficits. AVFs with tolerable symptoms and benign drainage patterns can be managed conservatively. Intolerable symptoms, presentation with hemorrhage/neurologic deficits, or aggressive drainage patterns are indications for intervention. Treatment options include microsurgical disconnection, endovascular transarterial embolization, transvenous embolization, or a combination. This is the first in a series of 3 articles on endovascular management of intracranial dural AVFs, in which we outline the principles and outcomes of endovascular treatment.
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Affiliation(s)
- K D Bhatia
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.) .,Department of Medical Imaging (K.D.B.), Sydney Children's Hospital Network, Westmead, New South Wales, Australia.,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of Sydney, Camperdown, New South Wales, Australia.,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia.,Division of Medical Imaging (K.D.B.), Faculty of Medicine, Macquarie University, Macquarie Park, New South Wales, Australia
| | - H Lee
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - H Kortman
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - J Klostranec
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - W Guest
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - T Wälchli
- Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - I Radovanovic
- Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.).,Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - V M Pereira
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.).,Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
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Lamanna A, Maingard J, Florescu G, Kok HK, Ranatunga D, Barras C, Lee MJ, Brooks DM, Jhamb A, Chandra RV, Asadi H. Endovascular balloon-assisted liquid embolisation of soft tissue vascular malformations: technical feasibility and safety. CVIR Endovasc 2021; 4:49. [PMID: 34101056 PMCID: PMC8187498 DOI: 10.1186/s42155-021-00236-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins without an intervening capillary system. The best endovascular treatment option for these is unclear and may involve multiple staged procedures using a variety of embolic materials. We report our initial experience using a modified version of a previously published neurointerventional technique to treat soft tissue AVMs with single-stage curative intent. Materials and methods Soft tissue AVMs treated endovascularly using either sole arterial or combined arterial and venous balloon-assisted techniques with liquid embolic agents were retrospectively identified over a 3.5 year period (January 2017 to June 2020)) at two centres. Clinical, pre-operative radiological, procedural technical and post treatment details were recorded. Results Seven patients were treated for symptomatic soft tissue arteriovenous malformations. These AVMs were located in the peripheral limbs (five), tongue (one) and uterus (one). Curative treatment was achieved in 6/7 patients with one patient requiring a second treatment approximately 1 year later. A variety of liquid embolisation agents (LEAs) including sclerosants and polymers were used. Clinical success rate was 100% following treatment. One patient experienced expected temporary post-operative tongue swelling requiring tracheostomy occurred following embolisation of the lingual AVM. A minor complication in a second patient was due to an access site haematoma developed following treatment of the hand AVM requiring surgical intervention. No long-term sequelae or additional complications were observed. Conclusion Endovascular arterial and venous balloon assisted LEA embolization of soft tissue AVMs with curative intent is feasible. This technique may provide an alternative treatment option for achieving durable occlusion for complex soft tissue AVMs.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia. .,Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia.
| | - Julian Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| | - Grace Florescu
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia
| | - Hong Kuan Kok
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia.,Interventional Radiology Service, Northern Health Radiology, Melbourne, Australia
| | - Dinesh Ranatunga
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia
| | - Christen Barras
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Michael J Lee
- Department of Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia.,Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.,Interventional Neuroradiology Service, Department of Radiology, St Vincent's Hospital, Melbourne, Australia
| | - Ashu Jhamb
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia.,Interventional Neuroradiology Service, Department of Radiology, St Vincent's Hospital, Melbourne, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia.,Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Australia.,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.,Interventional Neuroradiology Service, Department of Radiology, St Vincent's Hospital, Melbourne, Australia
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9
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Colasurdo M, Gabrieli JD, Cester G, Simonato D, Anglani M, Causin F. Hand-compression pressure cooker: an innovative variation of an existing technique with two example cases. Neuroradiol J 2021; 34:517-520. [PMID: 33829905 DOI: 10.1177/19714009211005995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The pressure cooker technique was originally ideated to obtain wedge-flow conditions during arteriovenous malformation or arteriovenous fistula embolisation. The anti-reflux plug created with coils or glue around the tip of a detachable microcatheter enables a continuous injection with a more in-depth penetration. Here we describe two illustrative cases performed with a variation of the technique that we describe as the hand-compression pressure cooker technique.
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Affiliation(s)
- Marco Colasurdo
- Department of Neuroradiology, The University of Texas Medical Branch at Galveston, USA
| | | | | | - Davide Simonato
- Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, UK
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Ghorbani M, Griessenauer CJ, Wipplinger C, Jabbour P, Asl MK, Rahbarian F, Mortazavi A. Adenosine-induced transient circulatory arrest in transvenous embolization of cerebral arteriovenous malformations. Neuroradiol J 2021; 34:509-516. [PMID: 33657933 DOI: 10.1177/1971400921998972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Due to advances in interventional techniques, the transvenous approach may present an effective treatment option for embolization of brain arteriovenous malformations (AVMs). Contrary to the transarterial method, the transvenous approach can only be utilized in a specific subset of patients and is not suitable as a standard procedure for all AVM lesions. While this technique can be helpful in certain patients, careful patient selection to ensure patient safety and favorable clinical outcomes is important. However, especially in high-flow AVMs, targeted deposition of embolic materials through a transvenous access can be challenging. Therefore, a temporary flow arrest may prove helpful. Transient cardiac arrest by use of adenosine has been applied in cerebrovascular surgery but is not common for endovascular embolization. Adenosine-induced arrest and systemic hypotension may be a feasible, safe method to reduce flow and help endovascular transvenous embolization of certain AVMs. Our study evaluated the efficiency and safety of adenosine-induced circulatory arrest for transvenous embolization of cerebral AVMs.
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Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | | | - Pascal Jabbour
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University Hospital, USA
| | - Mahdi Kadkhodazadeh Asl
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
| | - Farhad Rahbarian
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
| | - Abolghasem Mortazavi
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
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Nico L, Magro E, Ognard J, Fahed R, Salazkin I, Gevry G, Darsaut T, Raymond J, Gentric JC. Comparing N-hexyl cyanoacrylate (Magic Glue) and N-butyl cyanoacrylate (NBCA) for neurovascular embolization using the pressure cooker technique: An experimental study in swine. J Neuroradiol 2021; 48:486-491. [PMID: 33418056 DOI: 10.1016/j.neurad.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The pressure cooker (PC) technique uses a second microcatheter to produce a proximal occlusion to prevent the reflux of liquid embolic agent (LEA) injected through a more distal microcatheter, and can be used to treat arteriovenous malformations and dural arteriovenous fistulae. The liquid embolic Magic Glue (MG) (N-hexyl cyanoacrylate (NHCA)) has been introduced as an alternative to N-butyl cyanoacrylate (NBCA). Our goals were to compare the extent of embolization of rete mirabile with or without the PC technique using NBCA or MG, and to compare the proximal occlusions obtained with MG or NBCA while using the PC technique in a renal arterial model. METHODS Rete mirabile were embolized with (n = 4) and without (n = 4) the PC technique, using MG (n = 4) or NBCA (n = 4). A renal arterial model was then used to study the characteristics of the MG plug (n = 10) used for the PC technique, and resistance to catheter withdrawal as compared to NBCA (n = 4). Specimens were analyzed macro- and microscopically and compared to angiographic results. RESULTS Extent of rete embolization with CYA agents was not significantly greater when using the PC technique. Results were similar with both types of cyanoacrylate (p = 0.657). The force necessary to withdraw the microcatheter was less with MG than with NBCA (p = 0.035). CONCLUSION MG was similar to NBCA in extent of rete embolization. Less traction force was necessary to withdraw trapped non-detachable microcatheters using MG compared to NBCA.
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Affiliation(s)
- Lorena Nico
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France
| | - Elsa Magro
- Department of Neurosurgery, University Hospital of Brest. Bd. Tanguy Prigent, 29609 Brest Cedex, France; Laboratory of Medical Information Processing - LaTIM INSERM UMR 1101, Brest, France
| | - Julien Ognard
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France; Laboratory of Medical Information Processing - LaTIM INSERM UMR 1101, Brest, France
| | - Robert Fahed
- Department of Medicine, Division of Neurology, Ottawa Hospital, Ottawa, Canada
| | - Igor Salazkin
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Guylaine Gevry
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Tim Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Science Centre, Edmonton, Alberta, Canada
| | - Jean Raymond
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada; Department of Radiology, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Jean-Christophe Gentric
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France; Western Brittany Thrombosis Study Group - GETBO EA3878, Brest, France.
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Koyanagi M, Mosimann PJ, Nordmeyer H, Heddier M, Krause J, Narata AP, Serwi AE, Stracke CP, Chapot R. The transvenous retrograde pressure cooker technique for the curative embolization of high-grade brain arteriovenous malformations. J Neurointerv Surg 2020; 13:637-641. [PMID: 32900907 DOI: 10.1136/neurintsurg-2020-016566] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/21/2020] [Accepted: 08/23/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Transvenous embolization of brain arteriovenous malformations (AVMs) can be curative. We aimed to evaluate the cure rate and safety of the transvenous retrograde pressure cooker technique (RPCT) using coils and n-butyl-2-cyanoacrylate as a venous plug. METHODS All AVM patients treated via transvenous embolization between December 2004 and February 2017 in a single center were extracted from our database. Inclusion criteria were: inability to achieve transarterial cure alone; AVM < 3 cm; and single main draining vein. Outcome measures were immediate and 90 days' angiographic AVM occlusion rate, and morbidity and mortality at 30 days and 12 months, according to the modified Rankin Scale (mRS) score. RESULTS Fifty-one patients (20 women; median age 47 years) were included. A majority (71%) were high grade (3 to 5 in the Spetzler-Martin classification). AVMs were deeply seated in 30 (59%) and cortical in 21 patients (41%). Thirty-three patients were previously embolized transarterially (65%). All patients but one were cured within a single session with the RPCT (96%). Cure was confirmed on follow-up digital subtraction angiography at 3 months in 82% of patients. Three patients experienced intracranial hemorrhage (6%), one requiring surgical evacuation. There were no deaths. One treatment-related major permanent deficit was observed (2.0%). Mean mRS before treatment, at 30 days, and 12 months after RPCT was 1.5, 1.5, and 1.3, respectively. CONCLUSIONS The retrograde pressure cooker technique can be curative in carefully selected high-grade AVMs. Long-term follow-up and prospective studies are needed to confirm our results.
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Affiliation(s)
- Masaomi Koyanagi
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - Pascal John Mosimann
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - Hannes Nordmeyer
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - Markus Heddier
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - Juergen Krause
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - Ana-Paula Narata
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - Ahmed El Serwi
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - Christian Paul Stracke
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
| | - René Chapot
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Rüttenscheid, Essen, Germany
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Higbie C, Khatri D, Ligas B, Ortiz R, Langer D. N-Butyl Cyanoacrylate Transvenous Arteriovenous Malformation Embolization with Arterial Balloon Assistance: Defining Parameters for a Transvenous Approach as a Potential Upfront Treatment Option in Managing Cerebral Arteriovenous Malformations. Asian J Neurosurg 2020; 15:434-439. [PMID: 32656149 PMCID: PMC7335129 DOI: 10.4103/ajns.ajns_357_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/03/2020] [Accepted: 02/08/2020] [Indexed: 11/04/2022] Open
Abstract
Complete obliteration of arteriovenous malformations (AVMs) using a transvenous approach as the primary and stand-alone treatment modality has been increasingly considered as a useful endovascular approach in the treatment of AVMs. AVMs are typically treated with microsurgery, stereotactic radiosurgery, endovascular embolization, or some combination of the three methods. Preservation of the draining vein is a key requisite common to all treatment modalities. Transvenous embolization (TVE) is conventionally not recommended as a stand-alone treatment for the vast majority of AVMs and has been thought to be best indicated when traditional approaches are considered less safe and when specific evaluation criteria are met. We report a case of a 35-year-old asymptomatic male diagnosed with a small intracranial AVM adjacent to the right motor strip which was managed utilizing this approach. We employed endovascular embolization via a transvenous approach with arterial balloon assistance due to the small size of the nidus, eloquent location, en passage arterial supply proximal to the venous varix, and a single draining vein from the fistula. This case illustrates the selective indications and technical nuances of TVE approach in managing AVMs as a potential upfront treatment option. When patients harbor AVMs with specific angio-architectural findings as outlined, TVE utilizing Onyx or N-butyl cyanoacrylate can be safely performed as a primary treatment modality.
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Affiliation(s)
- Catherine Higbie
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Deepak Khatri
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Barbara Ligas
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Rafael Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
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Bhatia KD, Kortman H, Lee H, Waelchli T, Radovanovic I, Schaafsma JD, Pereira VM, Krings T. Facial Nerve Arterial Arcade Supply in Dural Arteriovenous Fistulas: Anatomy and Treatment Strategies. AJNR Am J Neuroradiol 2020; 41:687-692. [PMID: 32193191 DOI: 10.3174/ajnr.a6449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/14/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular treatment of petrous dural AVFs may carry a risk of iatrogenic facial nerve palsy if the facial nerve arterial arcade, an anastomotic arterial arch that supplies the geniculate ganglion, is not respected or recognized. Our purpose was to demonstrate that the use of a treatment strategy algorithm incorporating detailed angiographic anatomic assessment allows identification of the facial nerve arterial arcade and therefore safe endovascular treatment. MATERIALS AND METHODS This was a retrospective cohort study of consecutive petrous dural AVF cases managed at Toronto Western Hospital between 2006 and 2018. Our standard of care consists of detailed angiographic assessment followed by multidisciplinary discussion on management. Arterial supply, primary and secondary treatments undertaken, angiographic outcomes, and clinical outcomes were assessed by 2 independent fellowship-trained interventional neuroradiologists. RESULTS Fifteen patients had 15 fistulas localized over the petrous temporal bone. Fistulas in all 15 patients had direct cortical venous drainage and received at least partial supply from the facial nerve arterial arcade. Following multidisciplinary evaluation, treatment was performed by endovascular embolization in 8 patients (53%) and microsurgical disconnection in 7 patients (47%). All patients had long-term angiographic cure, and none developed iatrogenic facial nerve palsy. CONCLUSIONS By means of our treatment strategy based on detailed angiographic assessment and multidisciplinary discussion, approximately half of our patients with petrous AVFs were cured by endovascular treatment, half were cured by an operation, and all had preserved facial nerve function.
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Affiliation(s)
- K D Bhatia
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging
| | - H Kortman
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging
| | - H Lee
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging
| | - T Waelchli
- Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
| | - I Radovanovic
- Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
| | - J D Schaafsma
- Division of Neurology (J.D.S.), Department of Medicine, Toronto Western Hospital, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging.,Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
| | - T Krings
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging.,Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
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Soulez G, Gilbert, MD, FRCPC P, Giroux, MD, FRCPC MF, Racicot, MD, FRCPC JN, Dubois J. Interventional Management of Arteriovenous Malformations. Tech Vasc Interv Radiol 2019; 22:100633. [DOI: 10.1016/j.tvir.2019.100633] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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16
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He Y, Ding Y, Bai W, Li T, Hui FK, Jiang WJ, Xue J. Safety and Efficacy of Transvenous Embolization of Ruptured Brain Arteriovenous Malformations as a Last Resort: A Prospective Single-Arm Study. AJNR Am J Neuroradiol 2019; 40:1744-1751. [PMID: 31537516 DOI: 10.3174/ajnr.a6197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/23/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The efficacy and safety of transvenous embolization for brain arteriovenous malformations remains unclear, given the very limited number of cases reported. This prospective study was performed to assess this technique in ruptured AVMs. MATERIALS AND METHODS Twenty-one consecutive patients with ruptured brain AVMs who underwent transvenous embolization were prospectively followed between November 2016 and November 2018. The Spetzler-Martin grade was I in 3 AVMs (14.3%), II in four (19.0%), III in eleven (52.4%), and IV in three (14.3%). The complete AVM occlusion rate was calculated from 6-month follow-up DSA images. Occurrence of hemorrhage and infarction after embolization was evaluated using CT and MR imaging within 1 month after the operation. The mRS was used to assess the functional outcomes. RESULTS Complete AVM nidus obliteration was shown in 16 (84%) of 19 patients with technically feasible AVMs immediately after embolization. One (5%) patient with a small residual nidus after treatment showed complete obliteration at 13-month follow-up. There were 5 hemorrhages and 1 infarction; 4 patients' symptoms improved gradually. The percentage of cases with mRS ≤ 2 rose from 57.1% (12/21) before embolization to 66.7% (14/21) at 1-month follow-up. Both the morbidity and mortality rates were 4.8% (1/21). CONCLUSIONS Transvenous embolization can be performed only in highly selected hemorrhagic brain AVMs with high complete obliteration rates, improved functional outcomes, and acceptable morbidity and mortality rates, but it should not be considered as a first-line treatment.
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Affiliation(s)
- Y He
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
| | - Y Ding
- Department of Radiology (Y.D.), Mayo Clinic, Rochester, Minnesota
| | - W Bai
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
| | - T Li
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
| | - F K Hui
- Department of Radiology (F.K.H.), Johns Hopkins Hospital, Baltimore, Maryland
| | - W-J Jiang
- Department of Vascular Neurosurgery (W.-J.J.), the PLA Rocket Force General Hospital, Beijing, China
| | - J Xue
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
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Abstract
Objective The objective of this study was to evaluate the feasibility and outcomes of transvenous endovascular embolization (TVE) for superficial intracranial arteriovenous malformations (AVMs). Methods After collecting clinical and imaging data, a prospective series of 11 patients presenting with superficial AVMs were treated by endovascular embolization using a transvenous approach between November 2016 and October 2018. Results Ten patients (90.9%) had ruptured AVMs before TVE. The mean nidus size was 3.27 ± 1.47 cm, and the median Spetzler-Martin grade was II. The rate of immediate angiographic occlusion of the AVMs was 90.9% (10/11). One patient was treated with transarterial embolization since TVE was not achieved due to an unsuccessful positioning of the microcatheter. Two patients (cases 8 and 11) suffered a intracranial hemorrhage and a cerebral infarction with encephaledema, respectively, but no procedure-related mortalities were observed. Eight patients (72.7%) were independent with a modified Rankin Score (mRS) ≤ 2 at discharge and the mRSs of all patients, which were collected 30 days postintervention, were not more than 2. The mean follow-up period was 17 months. There were no nidus recurrences during the follow-up period. Conclusions The curative transvenous embolization of superficial AVMs seems feasible and effective while carefully monitoring for embolization-related complications.
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Zaki Ghali MG, Kan P, Britz GW. Curative Embolization of Arteriovenous Malformations. World Neurosurg 2019; 129:467-486. [DOI: 10.1016/j.wneu.2019.01.166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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Fang YB, Byun JS, Liu JM, Krings T, Pereira VM, Brinjikji W. Transvenous embolization of brain arteriovenous malformations: a systematic review and meta-analysis. J Neurosurg Sci 2019; 63:468-472. [DOI: 10.23736/s0390-5616.18.04342-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Fahed R, Darsaut TE, Mounayer C, Chapot R, Piotin M, Blanc R, Mendes Pereira V, Abud DG, Iancu D, Weill A, Roy D, Nico L, Nolet S, Gevry G, Raymond J. Transvenous Approach for the Treatment of cerebral Arteriovenous Malformations (TATAM): Study protocol of a randomised controlled trial. Interv Neuroradiol 2019; 25:305-309. [PMID: 30843441 PMCID: PMC6547200 DOI: 10.1177/1591019918821738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Transvenous embolisation is a promising technique but the benefits remain uncertain. We hypothesised that transvenous embolisation leads to a higher rate of arteriovenous malformation angiographic occlusion than transarterial embolisation. METHODS The Transvenous Approach for the Treatment of cerebral Arteriovenous Malformations (TATAM) is an investigator initiated, multicentre, prospective, phase 2, randomised controlled clinical trial. To test the hypothesis that transvenous embolisation is superior to transarterial embolisation for arteriovenous malformation obliteration, 76 patients with arteriovenous malformations considered curable by up to two sessions of endovascular therapy will be randomly allocated 1:1 to treatment with either transvenous embolisation (with or without transarterial embolisation) (experimental arm) or transarterial embolisation alone (control arm). The primary endpoint of the trial is complete arteriovenous malformation occlusion, assessed by catheter cerebral angiography. Complete occlusions will be confirmed at 3 months, while incompletely occluded arteriovenous malformations, considered treatment failures, will then be eligible for complementary treatments by surgery, radiation therapy, or even transvenous embolisation. Standard procedural safety outcomes will also be assessed. Patient selection will be validated by a case selection committee, and participating centres with limited experience in transvenous embolisation will be proctored. DISCUSSION The TATAM trial is a transparent research framework designed to offer a promising but still unvalidated treatment to selected arteriovenous malformation patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT03691870.
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Affiliation(s)
- Robert Fahed
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Tim E Darsaut
- Department of Surgery, University of
Alberta Hospital, Edmonton, Canada
| | - Charbel Mounayer
- Service de Neuroradiologie, CHU
Dupuytren, Service de Neuroradiologie, Limoges, France
| | - René Chapot
- Department of Neuroradiology,
Alfried-Krupp Krankenhaus Hospital, Essen, Germany
| | - Michel Piotin
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Raphaël Blanc
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Daniel G Abud
- Division of Interventional
Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo,
Brazil
| | - Dana Iancu
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Lorena Nico
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Suzanne Nolet
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
| | - Guylaine Gevry
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
| | - Jean Raymond
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
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Deng X, Dong M, Peng C, Ding X, Wang K, Qin K, Chen G. Embolizing intracranial arteriovenous malformations with Onyx: experience at a single center with 250 patients. J Interv Med 2019; 1:164-169. [PMID: 34805845 PMCID: PMC8586546 DOI: 10.19779/j.cnki.2096-3602.2018.03.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective The aim of this study is to evaluate the embolization techniques, as well as the effects and complications, using the non-adhesive liquid embolic material Onyx in intracranial arteriovenous malformations (AVMs). Methods The study comprises a retrospective analysis of 250 patients with intracranial AVMs treated with Onyx in Guangdong General Hospital from Jan 2010 to Dec 2017. The therapeutic strategies, as well as embolization effects and complications, of Onyx are summarized. Results Of 250 cases, 170 were male and 80 were female. Following the Spetzler-Martin (S-M) grading system, there were 35 cases of grade I, 77 of grade II, 72 of grade III, 39 of grade IV, and 27 of grade V. All cases were treated with Onyx. In addition, 69 cases were treated with Glubran glue. The injected volume of Onyx per patient ranged from 1 mL to 10 mL. The largest volume of Onyx injected in one procedure was 10 mL. The cure rate was 67.9% (76/112) of grade I-II patients, 15.0% (11/72) of grade III patients, 7.7% (3/39) of grade IV patients, and 0% (0/27) of grade V patients. The total cure rate was 36.0% (90/250). The average number of targeted vascular branches per patient was 2.28. The microcatheter broke off in two cases. There were two patients who suffered an intracranial hemorrhage during the embolic procedure; in one of these two patients, the microcatheter also broke off. There were two patients who suffered an intracranial hemorrhage after the embolic procedure; one of them died. Seven cases suffered new-onset neurological deficits or their original symptoms deteriorated. Six of them improved or recovered within 3-6 months. The total complication rate was 5.2% (13/250). Conclusion The application of Onyx in intracranial AVMs is flexible, effective and safe, and may also reduce the complications.
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Affiliation(s)
- Xianming Deng
- Department of Neurosurgery, Guangdong General Hospital, Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China,Southern Medical University, Guangzhou, Guangdong Province, China
| | - Mengqi Dong
- Department of Neurosurgery, Guangdong General Hospital, Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Chao Peng
- Department of Neurosurgery, Guangdong General Hospital, Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Xiaowen Ding
- Department of Neurosurgery, Guangdong General Hospital, Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Kun Wang
- Department of Neurosurgery, Guangdong General Hospital, Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China,Southern Medical University, Guangzhou, Guangdong Province, China
| | - Kun Qin
- Department of Neurosurgery, Guangdong General Hospital, Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Guangzhong Chen
- Department of Neurosurgery, Guangdong General Hospital, Institute of Neuroscience, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China,Correspondence: Guangzhong Chen, 106# Zhongshan Er Road, Guangzhou 510080, China,
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Surgical management of complex brain arteriovenous malformations with hybrid operating technique: study protocol of a prospective registry and a pragmatic clinical trial. BMC Neurol 2019; 19:75. [PMID: 31039755 PMCID: PMC6492487 DOI: 10.1186/s12883-019-1289-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 03/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Complex brain arteriovenous malformations (bAVMs) in ≥3 Spetzler-Martin grades have long been challenges among cerebrovascular diseases. None of the traditional methods, such as microsurgical operation, endovascular intervention, or stereotactic radiotherapy, can completely eliminate complex bAVMs without a risk of neural function deterioration. The multistaged hybrid operation solved part of the challenge but remained risky in the installment procedures and intervals. The one-staged hybrid operation was applied in the surgical treatment of cerebrovascular diseases and proved to be a potentially safe and effective method for curing complex bAVMs. However, lacking the support of high-level evidence, its advantages remain unclear. This study was proposed to validate the benefits and risks of one-staged hybrid operation in the treatment of complex bAVMs, as well as its indications, key technologies, and workflows. METHODS The study is being conducted from Jan 2016 to Dec 2020 with 20 cooperation centers. It consists of 2 sets. The registry set is designed as a prospective real-world registry. The trial set is designed as a prospective pragmatic clinical trial, specifically for the patients with perforating arterial feeders. The two sets share a common grouping: the traditional operation group and the one-staged hybrid operation group. The assignment is based on the clinical condition in the registry set and is randomized in the trial set. End points will be evaluated at scheduled time points. The safety and efficiency of one-staged hybrid operation in treating complex bAVMs will be validated. DISCUSSION The study is designed for a real-world exploration of benefits and risks of one-staged hybrid operation in the treatment of complex bAVMs. The two-set design reduces the compromise of clinical practice due to the study and improves the statistical power and research quality with a practical sample size. In the study, advantages of the one-staged hybrid operation will be evaluated and compared to those of traditional operation. A spanning development of neurosurgical operation might be facilitated by the study, which means a higher cure rate and lower disability rate in patients with complex bAVMs. TRIAL REGISTRATION The study was retrospectively registered in ClinicalTrials.gov ( NCT03774017 ) on 11th Dec, 2018.
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Hou K, Ji T, Guo Y, Xu B, Xu K, Yu J. Current Status of Endovascular Treatment for Dural Arteriovenous Fistulas in the Superior Sagittal Sinus Region: A Systematic Review of the Literature. World Neurosurg 2019; 122:133-143. [DOI: 10.1016/j.wneu.2018.10.145] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
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Xu K, Yang X, Li C, Yu J. Current status of endovascular treatment for dural arteriovenous fistula of the transverse-sigmoid sinus: A literature review. Int J Med Sci 2018; 15:1600-1610. [PMID: 30588182 PMCID: PMC6299407 DOI: 10.7150/ijms.27683] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/14/2018] [Indexed: 12/27/2022] Open
Abstract
Most intracranial dural arteriovenous fistulae (DAVFs) involve the transverse-sigmoid sinus (TSS), and various types of endovascular treatment (EVT) have been involved in managing TSS DAVFs. A current, comprehensive review of the EVT of TSS DAVFs is lacking. This study used the PubMed database to perform a literature review on TSS DAVFs to increase the current understanding of this condition. For high-grade TSS DAVFs such as Borden type 3, the goal of EVT is curative treatment. However, for low-grade TSS DAVFs such as Borden type 1 and some Borden type 2 TSS DAVFs, symptom relief or elimination of cortical reflux may be sufficient. Currently, EVT has become the first-line treatment for TSS DAVFs, including transarterial embolization (TAE), transvenous embolization (TVE) or both. TAE alone and TSS balloon-assisted TAE are also commonly used. However, TVE for TSS DAVFs is recognized as the most effective treatment, including coil direct packing TSS, Onyx® (ethylene vinyl alcohol copolymer) TVE, and balloon-assisted Onyx® TVE, which are commonly applied. In addition, TSS reconstructive treatment can be an effective procedure to treat TSS DAVFs. EVT is accompanied with complications, including technique- and treatment-related complications. Although complications may occur, TSS DAVFs have an acceptable prognosis after EVT.
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Affiliation(s)
- Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Xue Yang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
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25
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Zaki Ghali G, Zaki Ghali MG, Zaki Ghali E. Transvenous embolization of arteriovenous malformations. Clin Neurol Neurosurg 2018; 178:70-76. [PMID: 30731326 DOI: 10.1016/j.clineuro.2018.08.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/06/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
Embolization of arteriovenous malformations is characteristically used as part of a multimodal treatment approach, pre-operatively to facilitate microsurgical resection or as a preradiosurgical adjunct. The concept of AVM cure via embolization alone has gained popularity in recent years. Embolization of AVMs has been most commonly performed transarterially, with the transvenous route traditionally eschewed given concern over precipitating premature venous occlusion and consequent hemorrhage. However, the transvenous approach in treating AVMs offers several distinct advantages compared to the transarterial route and can be used in instances when the latter is not feasible, with several series having proven its efficacy and safety. Conceptually, AVM embolization performed via the transvenous route achieves complete obliteration by directly and facilely targeting the nidus. Nidal embolisate penetration is facilitated by control of arterial inflow via systemic or local hypotension. Innovation in endovascular strategies has led to significantly improved obliteration rates. The experience with transvenous AVM embolization is reviewed and discussed.
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Affiliation(s)
- George Zaki Ghali
- United States Environmental Protection Agency, Arlington, VA 22202, USA; Department of Toxicology, Purdue University, West Lafayette, IN 47907, USA
| | - Michael George Zaki Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, 6560 Fannin Street, Houston, 77030, TX, United States; Deptartment of Neurological Surgery, Baylor College of Medicine, Houston, TX 77030, US.
| | - Emil Zaki Ghali
- Department of Medicine, Inova Alexandria Hospital, Alexandria 22304, USA; Department of Urological Surgery, El Gomhoureya General Hospital, Alexandria, Egypt
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26
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Bhogal P, AlMatter M, Hellstern V, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. High-Grade Dural Arteriovenous Fistulas : Use of Kaneka ED Coils with the Marathon Microcatheter for Transvenous Coil Embolization. Clin Neuroradiol 2018; 29:653-660. [PMID: 30167712 DOI: 10.1007/s00062-018-0724-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVF) are commonly encountered lesions that can be treated both transvenously, transarterially or using a combined approach. OBJECTIVE Transvenous coil embolization of DAVF is a recognized treatment option but can be challenging. In this context this article presents clinical experience using the Kaneka ED10 ExtraSoft coils in combination with the Marathon microcatheter to treat high grade DAVF. The physical properties of these coils and the microcatheter were also determined. MATERIAL AND METHODS All patients with high grade DAVF treated with the Marathon and the Kaneka ED COIL ∞10 ExtraSoft coils were retrospectively identified. The clinical presentation, location, grade of the lesion, clinical and radiological follow-up data were recorded. Bench side studies were performed to determine the physical properties of the Marathon catheter in comparison to the SL10 and Headway Duo as well the maximum width of the Kaneka pusher wire in comparison to Hypersoft, Target and Axium Prime coils. RESULTS A total of 8 patients with 9 DAVF with 3 Cognard 3 and 6 Cognard 4 lesions were identified. All the DAVF's were occluded either at the end of the procedure or on follow-up imaging. On bench side tests the Marathon microcatheter had the most flexible distal tip and distal shaft in comparison to the SL10 and Headway Duo. The proximal shaft of the Marathon was stiffer than the SL10. The Kaneka ED COIL ∞10 ExtraSoft had the smallest distal width and were the only coils tested that could be deployed through a Marathon microcatheter. CONCLUSION The combination of the Marathon microcatheter and Kaneka ED COIL ∞10 ExtraSoft is useful for the treatment of high grade DAVF.
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Affiliation(s)
- P Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany. .,Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.
| | - M AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - V Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
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Chen CJ, Norat P, Ding D, Mendes GAC, Tvrdik P, Park MS, Kalani MY. Transvenous embolization of brain arteriovenous malformations: a review of techniques, indications, and outcomes. Neurosurg Focus 2018; 45:E13. [DOI: 10.3171/2018.3.focus18113] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular embolization of brain arteriovenous malformations (AVMs) is conventionally performed from a transarterial approach. Transarterial AVM embolization can be a standalone treatment or, more commonly, used as a neoadjuvant therapy prior to microsurgery or stereotactic radiosurgery. In contrast to the transarterial approach, curative embolization of AVMs may be more readily achieved from a transvenous approach. Transvenous embolization is considered a salvage therapy in contemporary AVM management. Proposed indications for this approach include a small (diameter < 3 cm) and compact AVM nidus, deep AVM location, hemorrhagic presentation, single draining vein, lack of an accessible arterial pedicle, exclusive arterial supply by perforators, and en passage feeding arteries. Available studies of transvenous AVM embolization in the literature have reported high complete obliteration rates, with reasonably low complication rates. However, evaluating the efficacy and safety of this approach is challenging due to the limited number of published cases. In this review the authors describe the technical considerations, indications, and outcomes of transvenous AVM embolization.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Pedro Norat
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - George A. C. Mendes
- 3Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, France
| | - Petr Tvrdik
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Min S. Park
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - M. Yashar Kalani
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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He Y, Bai W, Li T, Hui FK, He Y, Xu B. Curative Transvenous Embolization for Ruptured Brain Arteriovenous Malformations: A Single-Center Experience from China. World Neurosurg 2018; 116:e421-e428. [PMID: 29753079 DOI: 10.1016/j.wneu.2018.04.223] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate feasibility and safety of transvenous embolization for brain arteriovenous malformations (AVMs). METHODS Between November 2016 and August 2017, a transvenous endovascular embolization protocol was implemented at the Henan Provincial People's Hospital for consecutive patients with ruptured brain AVMs. Therapeutic decision making was based on Spetzler-Martin grade, brain AVM location, pattern of venous drainage, and angioarchitecture. Transvenous embolization was combined with transarterial support. Complete angiographic obliteration of the nidus was the objective of treatment. RESULTS Among 10 patients with ruptured brain AVMs, 8 were male. Spetzler-Martin grades before transvenous embolization were IV in 3 patients, III in 5 patients, II in 1 patient, and I in 1 patient. Modified Rankin Scale score before the procedure was 0-2 for 6 of 10 patients. Five patients also had deep venous drainage. Arterial blood pressure control and venous pressure cooker technique were used in all 10 patients; 9 patients had immediate angiographic occlusion. Two patients had a ventricular hemorrhage, which did not cause any disability after medical treatment. Seven patients underwent angiography 3-5 months after the procedure, and complete obliteration of the nidus was confirmed. Median clinical follow-up for all 10 patients was 8 months (range, 3-12 months). Epilepsy occurred in 1 patient 3 months after the procedure, and modified Rankin Scale scores for all patients were ≤1. CONCLUSIONS Transvenous embolization of brain AVMs is feasible and may improve cure rates. The safety and long-term effects need further validation.
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Affiliation(s)
- Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
| | - Weixing Bai
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China.
| | - Ferdinand K Hui
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yanyan He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
| | - Bin Xu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
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Lv X, Song C, He H, Jiang C, Li Y. Transvenous retrograde AVM embolization: Indications, techniques, complications and outcomes. Interv Neuroradiol 2017; 23:504-509. [PMID: 28675345 PMCID: PMC5624411 DOI: 10.1177/1591019917716817] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Transvenous retrograde arteriovenous malformation (AVM) embolization (TRAE) has been proposed. The present study was to review the techniques, their conjunctions and effectiveness. Methods Eligible related articles were identified by searching the PubMed and Web of Science databases using "transvenous" and "arteriovenous malformation." Results A total of 16 eligible studies, with 60 cases of AVM treated with TRAE, were analyzed. Prior to TRAE procedure, transarterial Onyx 18 was performed in 23 (38.3%), cyanoacrylate in three (5%) and coiling in two (3.3%), neurosurgery in one (1.7%) and radiosurgery in three (5%). These prior treatments were used to reduce the size of the nidus to <3 cm and TRAE was performed. One anterior choroidal artery aneurysm was coiled before TRAE. Systemic hypotension (blood pressure<100 mmHg) occurred in six (10%) patients and local hypotension (proximal arterial temporary balloon protection) in five (8.3%) patients. Complete obliteration was achieved in 56 (93.3%) AVMs, four (6.7%) with residual, of which one was supplemented with radiosurgery. During mean one-year follow-up (1 month to 3.2 years), there were five cases (8.3%) of permanent disability and one (1.7%) mortality resulting from initial hemorrhage. Fifty-four (90%) patients were independent (mRS ≤ 2) at follow-up. Ruptured AVMs and Spetzler-Martin I-III were associated with a high cure rate. Conclusion According to previous reports, selected AVMs could undergo TRAE. TRAE is safe and curative with Onyx after the nidus size is reduced sufficiently by transarterial embolization, neurosurgery or radiosurgery, with or without the aid of proximal arterial temporary balloon protection.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Cao Song
- Neurosurgery Department, Jilin Center Hospital, People’s Republic of China
| | - Hongwei He
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Chuhan Jiang
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Youxiang Li
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
- Youxiang Li, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Tiantan, Xili, 6, Dongcheng, Beijing, 100050, China.
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Lv X, Hu X, Li W, He H, Jiang C, Li Y. Curative and adjunctive AVM Onyx embolization of AVMs through the choroidal arteries. Interv Neuroradiol 2017; 23:392-398. [PMID: 28530159 PMCID: PMC5684906 DOI: 10.1177/1591019917706052] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective The anterior or posterior choroidal artery is often recruited to supply deep location arteriovenous malformations (AVMs). This study is to report curative and adjunctive AVM Onyx embolization through these arteries. Methods This study retrospectively reviewed six patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between October 2015 and October 2016. Embolization was performed as a curative procedure in five patients and adjunctive procedure in one patient. Results Four patients underwent embolization through the anterior choroidal artery (AchA), and two patients underwent embolization through the lateral posterior choroidal artery (LPchA). One of the four patients in whom embolization was from the AchA (distal to the plexal point) developed transient hemiparesis. Complete obliteration was confirmed by angiography at the last follow-up in five patients. Conclusions Onyx embolization of cerebral AVMs through the choroidal arteries is possible as a curative or adjunctive procedure.
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Affiliation(s)
| | | | | | | | - Chuhan Jiang
- Chuhan Jiang, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No. 6, Beijing, 100050, China.
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Viana DC, de Castro-Afonso LH, Nakiri GS, Monsignore LM, Trivelato FP, Colli BO, Abud DG. Extending the indications for transvenous approach embolization for superficial brain arteriovenous malformations. J Neurointerv Surg 2017; 9:1053-1059. [PMID: 28600483 DOI: 10.1136/neurintsurg-2017-013113] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/13/2017] [Accepted: 05/16/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Transarterial embolization is the standard endovascular treatment strategy for intracranial arteriovenous malformations (AVMs). The transvenous approach has been indicated for the embolization of deep AVMs meeting a set of strict eligibility criteria. The present study aims to assess the safety and efficacy of the transvenous approach for superficial AVMs. METHODS A retrospective series of 12 patients presenting with cortical AVMs were treated by endovascular embolization using a transvenous approach with a curative intent. RESULTS Nine patients (75%) had ruptured AVMs at admission. The mean nidus size was 1.9 cm, six patients (50%) had a nidus in eloquent areas and the median Spetzler-Martin grade was 2. The rate of immediate angiographic occlusion of the AVMs was 91.6% (11/12). One patient in whom immediate angiographic occlusion was not achieved showed spontaneous occlusion at the 6-month follow-up. No procedural or clinical complications were observed. The mean and median modified Rankin scale (mRS) scores at discharge were 1.7 and 2 (range 0-3, SD=0.96), and the mean and median mRS scores at 6 months were 1.6 and 2 (0-3, 1.16). Nine patients (75%) were independent (mRS ≤2) at discharge and 11 patients (91.6%) were independent (mRS ≤2) at the 6-month follow-up. CONCLUSIONS The curative transvenous embolization of superficial intracranial AVMs is feasible and appears safe and effective when strict anatomical selection is respected. This technique extends the current indications for transvenous embolization of intracranial AVMs and may improve cure rates while reducing embolization-related complications.
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Affiliation(s)
- Dinark Conceição Viana
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Luis Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Lucas Moretti Monsignore
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Felipe Padovani Trivelato
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
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