1
|
Su L, Yang X, Wang Z, Wen M, Fan X, Wang D. Eradication of the nidus in arteriovenous malformations with a dominant outflow vein in the lower extremities using coils and absolute ethanol. J Vasc Surg Venous Lymphat Disord 2023; 11:809-815. [PMID: 37076100 DOI: 10.1016/j.jvsv.2022.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 04/21/2023]
Abstract
OBJECTIVE In the present study, we summarize our experience in locating the nidus of arteriovenous malformations (AVMs) with a dominant outflow vein (DOV) in the lower extremities and eradicating the nidus with ethanol and coils. METHODS Twelve patients with lower extremity AVMs who underwent ethanol embolization combined with DOV occlusion from January 2017 to May 2018 were enrolled in the present study. Selective angiography was used to locate the nidus of the AVMs, which was eradicated using ethanol and coils via the direct puncture pathway. All treated patients underwent postoperative follow-up (mean, 25.5 months; range, 14-37 months). RESULTS The 12 patients underwent a total of 29 procedures (mean, 2.4; range, 1-4) with 27 detachable coils and 169 Nester coils (Cook Medical Inc, Bloomington, IN). Of the 12 patients, 7 (58.3%) had a complete response and 5 (41.7%) a partial response. Three patients (25%) had minor complications such as blister and superficial skin ulcers during follow-up. However, they recovered spontaneously and completely. No major complications were recorded. CONCLUSIONS Ethanol embolization combined with coil-assisted DOV occlusion has the potential to eradicate the nidus of lower extremity AVMs with acceptable complication rates.
Collapse
Affiliation(s)
- Lixin Su
- Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xitao Yang
- Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenfeng Wang
- Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mingzhe Wen
- Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xindong Fan
- Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Deming Wang
- Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| |
Collapse
|
2
|
Rivera R, Cespedes A, Cruz JP, Rivera GC, Valencia A, Rouchaud A, Mounayer C. Endovascular treatment simulations using a novel in vitro brain arteriovenous malformation model based on three-dimensional printing millifluidic technology. Interv Neuroradiol 2023:15910199231184605. [PMID: 37350047 DOI: 10.1177/15910199231184605] [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: 06/24/2023] Open
Abstract
BACKGROUND Brain arteriovenous malformations (bAVM) are complex vascular diseases. Several models have been used to simulate endovascular treatments; thus in vitro models have not been widely employed because it has been difficult to recreate realistic phantoms of this disease. OBJECTIVE To describe the development and evaluate the preliminary experience of a novel bAVM in vitro model for endovascular embolization using millifluidic three-dimensional (3D) printing technology. METHODS We designed a bAVM phantom starting from simple to more complex designs, composed of a nidus, feeding arteries and draining vein. We recreate the design by using millifluidic technology with stereolithography 3D printing. Structural and functional tests were performed using angiographic images and computer flow dynamics. Treatment simulations with ethylene vinyl alcohol were tested using two different microcatheter position techniques. A Likert-scale questionnaire was applied to perform a qualitative evaluation of the model. RESULTS We developed a realistic model of a bAVM with hollow channels. The structural evaluation showed a high precision of the 3D printing process. Embolization tests with the liquid agent gave similar sensations and material behaviour as in vivo cases. There were no significant differences between microcatheter position techniques, thus we observed a trend for better nidus filling with a deeper in-nidus position technique. CONCLUSIONS We were able to create and test a novel bAVM in vitro model with stereolithography 3D printing in resin. It showed a high capacity for simulating endovascular embolization characteristics, with an excellent user experience. It could be potentially used for training and testing of bAVM embolizations.
Collapse
Affiliation(s)
- Rodrigo Rivera
- Neuroradiology Department, Instituto de Neurocirugia Dr Asenjo, Santiago, Chile
- CNRS XLIM UMLR 7252, Université de Limoges, Limoges, France
| | - Alvaro Cespedes
- Department of Design and Manufacturing, Universidad Santa Maria, Viña del Mar, Chile
| | - Juan Pablo Cruz
- Neuroradiology Department, Instituto de Neurocirugia Dr Asenjo, Santiago, Chile
| | | | - Alvaro Valencia
- Department of Mechanical Engineering, Universidad de Chile, Santiago, Chile
| | - Aymeric Rouchaud
- CNRS XLIM UMLR 7252, Université de Limoges, Limoges, France
- Neuroradiology Department, CHU, Limoges, France
| | - Charbel Mounayer
- CNRS XLIM UMLR 7252, Université de Limoges, Limoges, France
- Neuroradiology Department, CHU, Limoges, France
| |
Collapse
|
3
|
Transvenous Embolization Technique for Brain Arteriovenous Malformations. Neurosurg Clin N Am 2022; 33:185-191. [DOI: 10.1016/j.nec.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
4
|
Rivera R, Cruz JP, Merino-Osorio C, Rouchaud A, Mounayer C. Brain arteriovenous malformations: A scoping review of experimental models. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
5
|
Waqas M, Dossani RH, Vakharia K, Rai HH, Chin F, Tso MK, Rajah GB, Snyder KV, Davies JM, Levy EI, Iyer VS, Siddiqui AH. Complete flow control using transient concurrent rapid ventricular pacing or intravenous adenosine and afferent arterial balloon occlusion during transvenous embolization of cerebral arteriovenous malformations: case series. J Neurointerv Surg 2021; 13:324-330. [PMID: 33593797 DOI: 10.1136/neurintsurg-2020-016945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are no reports that describe complete flow control using concurrent transient rapid ventricular pacing or intravenous (IV) adenosine and afferent arterial balloon flow arrest to aid transvenous embolization of cerebral arteriovenous malformations (AVM). We describe our experience with the use of this technique in patients undergoing transvenous AVM embolization. METHODS Consecutive patients in whom transvenous embolization was attempted at our institute between January 2017 and July 2019 were included. Anatomical AVM features, number of embolization stages, technique of concurrent transient rapid ventricular pacing and afferent arterial balloon flow arrest, complications, and clinical and radiological outcomes were recorded and tabulated. RESULTS Transvenous AVM embolization was attempted in 12 patients but abandoned in two patients for technical reasons. Complete embolization was achieved in 10 patients, five of whom had infratentorial AVMs. All 10 had a single primary draining vein. Rapid ventricular pacing was used in nine cases; IV adenosine injection was used in one case to achieve cardiac standstill. Complete AVM nidus obliteration was achieved with excellent neurologic outcome in nine cases, with transvenous embolization alone in two cases, and with staged transarterial followed by transvenous embolization in the others. Two patients developed hemorrhagic complications intraprocedurally. One patient was managed conservatively and the other operatively with AVM excision and hematoma evacuation; both made an excellent recovery without any neurologic deficits at 3 months. CONCLUSION Complete flow control using concurrent transient rapid ventricular pacing with afferent arterial balloon flow arrest technique is safe and feasible for transvenous embolization of select AVMs.
Collapse
Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Hamid H Rai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Felix Chin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Michael K Tso
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Gary B Rajah
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Vijay S Iyer
- Department of Cardiology, Gates Vascular Institute att Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA .,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Telischak NA, Yedavalli V, Massoud TF. Tortuosity of superior cerebral veins: Comparative magnetic resonance imaging morphometrics in normal subjects and arteriovenous malformation patients. Clin Anat 2020; 34:326-332. [PMID: 32196753 DOI: 10.1002/ca.23589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 12/23/2022]
Abstract
Blood vessel tortuosity results from increased diameter and length in response to higher hemodynamic loads. Tortuosity metrics have not been determined for abnormal superior cerebral veins (SCVs) draining cerebral arteriovenous malformations (AVMs). Draining vein (DV) tortuosity may influence safety and efficacy of retrograde microcatheter navigation during transvenous treatment of pial AVMs. Here, we quantify SCV tortuosity in normal subjects and AVM patients using two image segmentation methods. We used contrast-enhanced brain magnetic resonance (MR) images to define the axis of each SCV through a regularly spaced set of three-dimensional (3D) points defining its skeleton curve. We then calculated two metrics: the "sum of angles metric" (SOAM), which adds all angles of curvature along a vessel and normalizes by vessel length, and the "distance metric" (DM), a tortuosity measure providing a ratio of vessel length to linear distance between vessel endpoints. We analyzed 168 metrics in 43 veins of eight normal subjects and 41 veins of seven AVM patients. In normal subjects, the mean SOAM and DM for SCVs were 21.34 ± 7.49 °/mm and 1.42 ± 0.25, respectively. In AVM patients, DVs had a significantly higher mean SOAM of 30.43 ± 11.38 °/mm (p = .02) and DM of 2.79 ± 1.77 (p = .01) than normal subjects. In AVM patients, DVs were significantly more tortuous than matched contralateral uninvolved SCVs, which were similar in tortuosity to normal subject SCVs. We thus report normative tortuosity metrics of brain SCVs and show that AVM cortical DVs are significantly more tortuous than normal SCVs. Knowledge of these comparative tortuosities is valuable in planning endovenous AVM embolotherapies.
Collapse
Affiliation(s)
- Nicholas A Telischak
- Division of Neuroimaging and Neurointervention, Stanford Initiative for Multimodality neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Vivek Yedavalli
- Division of Neuroimaging and Neurointervention, Stanford Initiative for Multimodality neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Stanford Initiative for Multimodality neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
8
|
Yedavalli V, Telischak NA, Jain MS, Massoud TF. Three-Dimensional Angles of Confluence of Cortical Bridging Veins and the Superior Sagittal Sinus on MR Venography: Does Drainage of Adjacent Brain Arteriovenous Malformations Alter this Spatial Configuration? Clin Anat 2019; 33:293-299. [PMID: 31749197 DOI: 10.1002/ca.23521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 10/27/2019] [Indexed: 11/11/2022]
Abstract
Few neuroimaging anatomic studies to date have investigated in detail the point of entry of cortical bridging veins (CBVs) into the superior sagittal sinus (SSS). Although we know that most CBVs join the SSS at an acute angle opposite to the direction of SSS blood flow, the three-dimensional (3-D) spatial configuration of these venous confluences has not been studied previously. This anatomical information would be pertinent to several clinically applicable scenarios, such as in planning intracranial surgical approaches that preserve bridging veins; studying anatomical factors in the pathophysiology of SSS thrombosis; and when planning endovascular microcatheterization of pial veins to retrogradely embolize brain arteriovenous malformations (AVMs). We used the concept of Euclidean planes in 3-D space to calculate the arccosine of these CBV-SSS angles of confluence. To test the hypothesis that pial AVM draining veins may not be any more acutely angled or difficult to microcatheterize at the SSS than for normal CBVs, we measured 70 angles of confluence on magnetic resonance venography images of 11 normal, and nine AVM patients. There was no statistical difference between normal and AVM patients in the CBV-SSS angles projected in 3-D space (56.2° [SD = 22.4°], and 46.2° [SD = 22.3°], respectively; P > 0.05). Hence, participation of CBVs in drainage of pial AVMs should not confer any added difficulty to their microcatheterization across the SSS, when compared to the acute angles found in normal individuals. This has useful implications for potential choices of strategies requiring endovascular transvenous retrograde approaches to treat AVMs. Clin. Anat. 33:293-299, 2020. © 2019 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Vivek Yedavalli
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Nicholas A Telischak
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Mika S Jain
- Department of Physics, Stanford University School of Humanities and Sciences, Stanford, California.,Department of Computer Science, Stanford University School of Engineering, Stanford, California
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
9
|
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]
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Fennell VS, Martirosyan NL, Atwal GS, Kalani MYS, Ponce FA, Lemole GM, Dumont TM, Spetzler RF. Hemodynamics Associated With Intracerebral Arteriovenous Malformations: The Effects of Treatment Modalities. Neurosurgery 2017; 83:611-621. [DOI: 10.1093/neuros/nyx560] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 10/13/2017] [Indexed: 12/22/2022] Open
Abstract
Abstract
The understanding of the physiology of cerebral arteriovenous malformations (AVMs) continues to expand. Knowledge of the hemodynamics of blood flow associated with AVMs is also progressing as imaging and treatment modalities advance. The authors present a comprehensive literature review that reveals the physical hemodynamics of AVMs, and the effect that various treatment modalities have on AVM hemodynamics and the surrounding cortex and vasculature. The authors discuss feeding arteries, flow through the nidus, venous outflow, and the relative effects of radiosurgical monotherapy, endovascular embolization alone, and combined microsurgical treatments. The hemodynamics associated with intracranial AVMs is complex and likely changes over time with changes in the physical morphology and angioarchitecture of the lesions. Hemodynamic change may be even more of a factor as it pertains to the vast array of single and multimodal treatment options available. An understanding of AVM hemodynamics associated with differing treatment modalities can affect treatment strategies and should be considered for optimal clinical outcomes.
Collapse
Affiliation(s)
- Vernard S Fennell
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Gursant S Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - G Michael Lemole
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Zhang G, Zhu S, Wu P, Xu S, Shi H. The transvenous pressure cooker technique: A treatment for brain arteriovenous malformations. Interv Neuroradiol 2016; 23:194-199. [PMID: 27913800 DOI: 10.1177/1591019916682357] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The treatment of brain arteriovenous malformations (AVMs) remains a significant challenge, especially hemorrhagic AVMs which are unsuitable for microsurgery or radiosurgery. We demonstrate an AVM located in the left basal ganglia area, supplied by slender arteries, and treated by the transvenous pressure cooker technique. Herein, we describe the procedure and outline the crucial points and indications for this technique.
Collapse
Affiliation(s)
- Guang Zhang
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shiyi Zhu
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pei Wu
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shancai Xu
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Huaizhang Shi
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| |
Collapse
|
15
|
Papagiannaki C, Clarençon F, Ponsonnard S, Couquet C, Maizeroi-Eugène F, Bresson D, Yardin C, Mounayer C. Development of an angiogenesis animal model featuring brain arteriovenous malformation histological characteristics. J Neurointerv Surg 2016; 9:204-210. [PMID: 27013231 DOI: 10.1136/neurintsurg-2015-012173] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/28/2016] [Accepted: 03/01/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Angiogenesis has a key role in the formation and evolution of brain arteriovenous malformations (AVMs). Numerous models have been developed aiming to recreate configuration of brain AVMs. OBJECTIVE To develop an animal model sharing the same pathological characteristics as human brain AVMs. MATERIALS AND METHODS Ten pigs were divided into two groups. Five animals underwent endovascular left common carotid artery (CCA) and external carotid artery (ECA) occlusion and five animals served as controls. DSA, associated with 3D-rotational angiography, was performed at day 0 and at 3 months in both groups. The volume of the retia was calculated. Vascular endothelial growth factor (VEGF)-A serum levels were measured in both groups at the same time intervals. Finally, the animals were sacrificed at 3 months and the retia were harvested for pathological and immunohistochemistry examinations. RESULTS At 3 months, a significantly higher rete volume was seen in group A than in group B (2.92±0.33 mL vs 1.87±0.69 mL, respectively; p=0.016). There was a trend for increased VEGF-A levels in group A at 3 months. In the occlusion group, histological findings showed significant reduction of media thickness and disrupted internal elastic lamina; immunohistochemistry findings showed strong reactivity for VEGF receptors and interleukin 6. CONCLUSIONS Unilateral endovascular occlusion of the CCA-ECA results in angiogenesis triggering of the rete mirabile with both significant augmentation of the rete volume and histological evidence of pro-angiogenic stimulation.
Collapse
Affiliation(s)
- Chrysanthi Papagiannaki
- ERMA (Equipe de Recherche Medicale Appliquée), Limoges University Hospital, Limoges, France.,Interventional Neuroradiology Department, Rouen University Hospital, Rouen, France
| | - Frédéric Clarençon
- ERMA (Equipe de Recherche Medicale Appliquée), Limoges University Hospital, Limoges, France.,Interventional Neuroradiology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Sébastien Ponsonnard
- ERMA (Equipe de Recherche Medicale Appliquée), Limoges University Hospital, Limoges, France.,Anesthesiology Department, Limoges University Hospital, Limoges, France
| | - Claude Couquet
- Haute Vienne Departmental Laboratory for Research and Analysis, Limoges, France
| | | | - Damien Bresson
- Department of Neurosurgery, Lariboisière University Hospital, Paris, France
| | - Catherine Yardin
- ERMA (Equipe de Recherche Medicale Appliquée), Limoges University Hospital, Limoges, France.,Department of Histology, Cytology, Cellular Biology and Cytogenetics, Limoges University Hospital, Limoges, France
| | - Charbel Mounayer
- ERMA (Equipe de Recherche Medicale Appliquée), Limoges University Hospital, Limoges, France.,Department of Interventional Neuroradiology, Limoges University Hospital, Limoges, France
| |
Collapse
|
16
|
Orlov KY, Berestov VV, Krivoshapkin AL, Panarin VA, Kislitsin DS, Gorbatykh AV, Shayakhmetov TS, Seleznev PO. [Transarterial and transvenous embolization of deep binodal arteriovenous malformation of the brain]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:85-89. [PMID: 26529538 DOI: 10.17116/neiro201579385-89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The multimodal approach to treatment of arteriovenous malformations yields good results. However, small and deep malformations still pose a big problem for surgeons. Transvenous embolization was designed as an alternative for the cases when endovascular treatment is required and conventional transarterial embolization is not available. CASE STUDY A 41-year-old patient with binodal malformation in the subcortical nuclei of the left hemisphere of the brain, which had previously become a source of massive parenchymal ventricular hemorrhage, was operated on using the transarterial and, for the first time in our clinic, transvenous approaches. Transarterial embolization of the thalamic node of malformation was performed as the first step. After 6 months, transvenous embolization of the hypothalamic node of malformations was performed as the second step. Successful operation was ensured by using a stable coaxial guiding catheter system with the maximum distal approach and intranidal positioning of a microcatheter with detachable distal portion upon temporary occlusion of afferent vessels of the malformations using a balloon catheter. The operation resulted in total thrombosis of the malformation. No perioperative complications were observed. Control examination in 6 months did not reveal recanalization of the malformation. CONCLUSION The transvenous approach can be successfully used in endovascular treatment of small and deep arteriovenous malformations with a single drainage vein, which are inaccessible to direct surgery. It can also be used when radiosurgery is associated with a high risk in cases where transarterial embolization is infeasible.
Collapse
Affiliation(s)
- K Yu Orlov
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - V V Berestov
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - A L Krivoshapkin
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia; Novosibirsk State Medical University, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - V A Panarin
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - D S Kislitsin
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - A V Gorbatykh
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - T S Shayakhmetov
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - P O Seleznev
- Meshalkin Research Institute of Circulation Pathology, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| |
Collapse
|
17
|
Choudhri O, Ivan ME, Lawton MT. Transvenous Approach to Intracranial Arteriovenous Malformations. Neurosurgery 2015; 77:644-51; discussion 652. [DOI: 10.1227/neu.0000000000000869] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
A compartmental conceptualization of intracranial arteriovenous malformations (AVMs) allows recognition of feeding arteries, an intervening plexiform nidus, and draining veins. AVM therapy involves eliminating the nidus, which is the source of hemorrhage, without compromising normal arterial and venous drainage of the brain. Traditional methods of AVM therapy through microsurgery and endovascular embolization involve arterial devascularization, with preservation of AVM venous drainage, until the nidus is excluded. The transvenous approach in treating vascular malformations was popularized by successful treatment models for dural arteriovenous fistulas. More recently, high-flow intracranial AVMs are being managed with transvenous endovascular approaches, although this novel technique has its challenges and perils. We review the current literature on transvenous AVM therapy and highlight its role for AVM therapy in the present day.
Collapse
Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael E. Ivan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| |
Collapse
|
18
|
Brain AVMs: an endovascular, surgical, and radiosurgical update. ScientificWorldJournal 2014; 2014:834931. [PMID: 25401156 PMCID: PMC4221901 DOI: 10.1155/2014/834931] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 08/01/2014] [Indexed: 11/17/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are complex vascular lesions. Despite multiple studies, several classifications, and a great interest of the scientific community, case selection in AVM patients remains challenging. During the last few years, tremendous advancements widened therapeutic options and improved outcomes spreading indications for patients harboring lesions deemed inoperable in the past. Anatomical and biological case specific features, and natural history with a focus on presenting symptoms should be evaluated case by case and always kept in mind while planning a therapeutic management for a bAVMs. A multidisciplinary approach is strongly recommended when dealing with bAVMs and should involve physicians expertise in this kind of challenging lesions. The goal of this paper is to provide a focused review of the most recent acquisitions and therapeutic strategies regarding surgical, endovascular, and radiosurgical treatment.
Collapse
|
19
|
Potts MB, Zumofen DW, Raz E, Nelson PK, Riina HA. Curing arteriovenous malformations using embolization. Neurosurg Focus 2014; 37:E19. [DOI: 10.3171/2014.6.focus14228] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular embolization is typically reserved as an adjuvant therapy in the management of cerebral arteriovenous malformations (AVMs), either for preoperative devascularization or preradiosurgical volume reduction. Curative embolization plays a limited role in AVM treatment but several studies have shown that it is possible, especially with later-generation liquid embolic agents. Given the complexity of AVM anatomy and the recent controversies over the role of any intervention in AVM management, it is critical that the cerebrovascular community better define the indications of each treatment modality to provide quality AVM management. In this review, the authors evaluate the role of curative AVM embolization. Important considerations in the feasibility of curative AVM embolization include whether it can be performed reliably and safely, and whether it is a durable cure. Studies over the past 20 years have begun to define the anatomical factors that are amenable to complete endovascular occlusion, including size, feeding artery anatomy, AVM morphology, and endovascular accessibility. More recent studies have shown that highly selected patients with AVMs can be treated with curative intent, leading to occlusion rates as high as 100% of such prospectively identified lesions with minimal morbidity. Advances in endovascular technology and techniques that support the efficacy and safety of curative embolization are discussed, as is the importance of superselective diagnostic angiography. Finally, the durability of curative embolization is analyzed. Overall, while still unproven, endovascular embolization has the potential to be a safe, effective, and durable curative treatment for select AVMs, broadening the armamentarium with which one can treat this disease.
Collapse
Affiliation(s)
- Matthew B. Potts
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Daniel W. Zumofen
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Eytan Raz
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Peter K. Nelson
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Howard A. Riina
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| |
Collapse
|