The Use of Transarterial Approaches in Peripheral Arteriovenous Malformations (AVMs)

Ethanol embolization of arteriovenous malformations in the buttock: ten-year experiences in diagnoses and treatment options

BACKGROUND

Clinically, arteriovenous malformations in the buttocks (bAVMs) are extremely rare. Our study aimed to evaluate the efficacy and safety of ethanol embolotherapy in managing bAVMs.

RESULTS

A total of 32 patients with bAVMs (14 females and 18 males) from 2012 to 2021 were included in this study. All patients underwent complete clinical and imaging examinations. Further, the AVMs lesions were analyzed according to Schöbinger staging and Yakes classification. Each patient had undergone a multistage ethanol embolization. The amelioration of clinical symptoms and devascularization on angiography were evaluated at regular follow-ups. In the present cohort, the 11-20 age group had the most patients (15/32; 46.88%). A total of 124 embolization procedures were performed (average 3.88 procedures per patient), and the average dose of absolute ethanol was 18.96 mL per procedure. Thirteen patients with dominant draining veins underwent additional coil deployment before ethanol embolization (13/32; 40.63%). During follow-ups, clinical improvement was found in 23 of 27 who presented with a pulsating mass (85.19%), 17 of 20 with abnormal local skin temperature (85%), 5 of 6 with bleeding (83.33%), and 5 of 5 patients treated for pain (100%). More than 75% angiographic devascularization was achieved in 18 patients (18/32; 56.25%). Finally, 12 out of 13 patients (92.31%) reduced from Schöbinger Stage III to a lower grade, and ten patients exhibited a complete response (10/32; 31.23%). There was a single serious complication of local necrosis, while neither paranesthesia nor infection was observed postoperatively.

CONCLUSIONS

Ethanol embolization assisted with coils can treat bAVMs effectively and safely. The Yakes classification contributed to the optimal ethanol embolotherapy of bAVMs.

An overview of interventional radiology techniques for the diagnosis and management of vascular anomalies: Part 2

Minimally invasive percutaneous and endovascular strategies performed by interventional radiologists have become the mainstays of treatment for vascular anomalies with improved outcomes, decreased complication rates, and less morbidity. The aim of this article is to introduce physicians who care for patients with vascular anomalies to state-of-the-art advancements in interventional radiology for diagnosis and treatment. Part 2 of this review discusses embolization, endovenous laser ablation, and image-guided percutaneous biopsy. Please see Part 1 for a discussion of sclerotherapy and cryoablation. Select vascular anomalies will be discussed as examples to highlight IR diagnostic and/or treatment techniques.

Eradication of the nidus in arteriovenous malformations with a dominant outflow vein in the lower extremities using coils and absolute ethanol

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.

Ethanol Embolization of Chest Wall Arteriovenous Malformations: Four-Year Findings

OBJECTIVES

To summarize the clinical characteristics and investigate the efficacy of ethanol embolotherapy in the treatment of chest well arteriovenous malformation (AVM). Treatment-associated complications were also explored.

MATERIALS AND METHODS

Between March 2017 and August 2021, 32 consecutive patients (mean age, 23.7 years; age range, 5-54 years) who underwent ethanol embolotherapy for chest well AVMs under general anesthesia were included in this study. Embolization was performed through a direct puncture, transarterial catheterization, or a combination of the 2 procedures. The mean follow-up duration after the last treatment was 18.0 months (range, 3-42 months). The degree of devascularization on follow-up (assessed using angiography or computed tomography), and the clinical signs and symptoms of AVMs were evaluated as the therapeutic outcomes. The major and minor complications associated with the procedures were recorded.

RESULTS

A total of 103 embolization procedures (mean, 3.2; range, 2-7) comprising 101 ethanol embolization and 2 coil embolizations were performed on 32 patients with chest wall AVMs. The AVM nidus was accessed through the transarterial approach alone in 4 patients, by direct puncture in 11, and a combined procedure in 17 patients. Overall, more than 80% of the procedures were performed using the combined approach. Complete AVM devascularization was achieved in 12 (37.5%) patients. Moreover, 76% to 99% AVM was achieved in 18 patients (56.3%), and 50% to 75% in 2 patients (6.3%). Bleeding, pain, heart failure, and cosmetic deformities were the indications for treatment. For 3 patients (3/32, 9.4%) who had bleeding, the treatment stopped the hemorrhage. Complete pain relief was reported in 8 patients (8/32, 25.0%), whereas complete relief from congestive heart failure post-embolization was observed in 5 of the 6 patients with congestive heart failure (5/6, 83.3%). Complete correction of cosmesis deformities after embolization was achieved in 10 patients (10/32, 31.3%). Two patients who underwent surgery to correct persistent deformity after embolization only showed insignificant improvement. In addition, 6 (18.8%) patients developed 13 complications including blister, necrosis, hemothorax, transient hemoglobinuria, and transient pulmonary artery hypertension.

CONCLUSIONS

Ethanol embolotherapy is a safe and effective procedure for chest well AVMs. Surgery is required for some patients with residual cosmesis deformity.

CLINICAL IMPACT

Currently, there is no standard treatment for chest well AVMs due to their rarity and high heterogeneity. The present study shows that thanol embolotherapy is a safe and clinically effective treatment procedure for the chest well AVMs. Transarterial embolization in combination with direct puncture embolization can reach the AVM nidus. Ethanol embolotherapy can achieve complete obliteration of the AVM nidus in the majority of patients. Surgery may still be needed to correct cosmetic deformity after embolization. The present study provides valuable evidence to inform clinical decision-making.

Shoulder Pain Associated With Multiple Arteriovenous Malformations Successfully Treated With Embolization

A 44-year-old male presented with left upper extremity and shoulder pain with worsening functional impairment after years of repetitive use, overtraining, and multiple injuries from weightlifting and mixed martial arts. Imaging showed no obvious injury or ligamentous deformity other than mild osteoarthritis (OA) of the left glenohumeral joint. Duplex ultrasonography (US) revealed four arteriovenous malformations (AVMs) surrounding the shoulder joint and left upper extremity. The vasculature was mapped via angiography through a transradial approach. Initial treatment included transarterial embolization of two AVMs off the axillary artery and branching anterior circumflex humeral artery. Secondary treatment included embolization of two lesions months later via direct puncture, one through a transvenous approach and the second through direct transmalformation cannulation, via the nidus, near the clavicle and posterior scapular lateral border. Treatment resulted in significant improvement in pain and range of motion. Follow-up assessments revealed improvement in overall symptoms, recovered function, and return to exercise and competitive mixed martial arts. This case highlights the value of duplex ultrasonography, embolization, and transarterial and transvenous approaches for the treatment of AVM-associated extremity or joint pain.

The trend of percutaneous and open surgical procedures for peripheral arteriovenous malformations in the National Health Service England

INTRODUCTION

This study aimed to assess the trend of percutaneous and open surgical procedures for peripheral arteriovenous malformations (AVMs) performed in NHS hospitals in England between 2012 and 2018.

METHODS

Hospital Episode Statistics (HES) is a freely available data warehouse that represents the whole population of England served by the NHS. Data from the HES database was obtained and analysed for all hospital episodes between 2012 and 2018 for the total number and trend of 'primary diagnosis', and 'primary procedures and interventions' identified for peripheral AVMs.

RESULTS

Over the period studied, there was an increase in the total number of admissions for peripheral AVMs; total primary diagnosis increased from 2242 to 2857 per year. Open surgery remained more commonly performed than percutaneous procedures throughout the studied period. However, the overall percentage of primary procedures and interventions being percutaneous in this period increased from 29.8% to 41.0% per year. The increase in the number of percutaneous procedures per year seemed to occur in both children (from 43 to 124) and adults (from 408 to 492) over the course of the study period.

CONCLUSIONS

This study concluded that open surgery remained the most commonly performed primary procedure for peripheral AVMs, although there was an increasing trend for percutaneous procedures in NHS hospitals in England. The increase in the number and percentage of percutaneous procedures for peripheral AVMs was likely to have significant resource implications for the provision of care for patients with peripheral AVMs in NHS hospitals.

Emerging Polymer Materials in Trackable Endovascular Embolization and Cell Delivery: From Hype to Hope

Minimally invasive endovascular embolization is a widely used clinical technique used for the occlusion of blood vessels to treat various diseases. Different occlusive agents ranging from gelatin foam to synthetic polymers such as poly(vinyl alcohol) (PVA) have been commercially used for embolization. However, these agents have some drawbacks, such as undesired toxicity and unintended and uncontrolled occlusion. To overcome these issues, several polymer-based embolic systems are under investigation including biocompatible and biodegradable microspheres, gelling liquid embolic with controlled occlusive features, and trackable microspheres with enhanced safety profiles. This review aims to summarize recent advances in current and emerging polymeric materials as embolization agents with varying material architectures. Furthermore, this review also explores the potential of combining injectable embolic agents and cell therapy to achieve more effective embolization with the promise of outstanding results in treating various devastating diseases. Finally, limitations and challenges in developing next-generation multifunctional embolic agents are discussed to promote advancement in this emerging field.

Endovascular interventions in the management of acute extremity trauma: a narrative review

Minimally invasive endovascular interventions including stenting and embolization have been widely adopted for the treatment of emergent and traumatic thoracoabdominal injuries. In recent years, these techniques have been utilized in the setting of extremity vascular trauma with promising outcomes. By allowing for the rapid diagnosis and subsequent treatment of penetrating or blunt vascular extremity trauma, these techniques can help to minimize blood loss, reduce operative complications, and potentially prevent limb amputation. Here, we present a narrative review of the ever-increasing role of minimally invasive interventions in the management of extremity trauma and compare its use and outcomes to open surgical repair. A special focus is placed on diagnostic imaging modalities in trauma and the role of interventional radiologists in the work-up and treatment of extremity trauma. We discuss diagnostic imaging modalities that aid in the triaging of extremity trauma, such as Doppler sonography, CT angiography, and catheter-based angiography. We present an overview on the literature related to endovascular interventions such as embolotherapy and stent grafting as well as the technical challenges associated with each technique. Finally, we present our own cases on the workup and endovascular treatment of extremity trauma, including CT angiography, particulate and coil embolization, and stent graft placement.

Uterine Arteriovenous Malformation: A Pictorial Review of Diagnosis and Management

Uterine arteriovenous malformation (UAVM) is a rare condition and is classified as either congenital or acquired UAVM. Patients with UAVMs usually experience miscarriages or recurrent menorrhagia. Ultrasound is used for the initial estimation of UAVMs. Computed tomography and magnetic resonance imaging are noninvasive and valuable methods that provide good compatibility with digital subtraction angiography to support the diagnosis and treatment of UAVM. Timely diagnosis is crucial to provide appropriate treatment for alleviating complications. This article presents a pictorial and literature review of the current evidence of the diagnosis and management of UAVM.

Proctalgia secondary to rectal arteriovenous malformation and inferior mesenteric vein stenosis in a patient post liver transplant

Background

Chronic proctalgia can have a major impact upon quality of life. There are many potential aetiologies however, in some patients no cause can be identified.

Case presentation

We present a patient post liver transplant with intractable proctalgia, despite multidisciplinary management including opioids, nerve blocks and surgical intervention. An underlying rectal arteriovenous malformation (AVM) was subsequently identified and successfully treated with embolotherapy. The onset of symptoms coincided with the development of inferior mesenteric vein stenosis, likely leading to engorgement of the malformation due to impaired venous outflow. Neovascularisation secondary to the liver transplant procedure may also have contributed to growth of the lesion.

Conclusion

This is a rare presentation of rectal AVM. These lesions can be treated with minimally invasive embolisation/sclerotherapy and should be considered in cases of unexplained proctalgia.

Vascular anomalies: Classification and management

Vascular anomalies are broadly classified into two major categories: vascular tumors and vascular malformations. Most vascular anomalies are caused by sporadic mosaic gene mutations, and recent genetic studies have advanced our understanding of the molecular pathways involved in their pathogenesis. These findings have suggested new therapeutic approaches to vascular anomalies, focusing on their pathogenetic mechanism. This chapter seeks to integrate an improved molecular understanding within the updated classification system of the International Society for Study of Vascular Anomalies. We emphasize the genetic, radiologic, and interventional aspects of diagnosis and management in hopes of allowing improved multidisciplinary collaboration surrounding these complex and interesting anomalies.

Torrential bleeding of arteriovenous malformation in hand post-ethanol sclerotherapy: A case report

Embolization or sclerotherapy is considered as the first-line therapy for the management of arteriovenous malformations (AVM) and can be performed directly targeting the nidus. Ethanol is an effective embolic agent; however, some complications may arise. This paper illustrates a case of torrential bleeding following ethanol sclerotherapy in a patient with progressive hand arteriovenous malformations with a poor prognosis and was suggested to be amputated. Direct pressure, tourniquet appliance, and split-thickness skin graft procedure were performed to stop the bleeding successfully. No recurrence of bleeding was reported; and complete alleviation of pain was achieved.