Endovascular treatment ofarterio-venous malformations:
effectiveness and safety
LINC 2018
Leipzig, Germany, 31. Jan 2018
Walter A. Wohlgemuth
University Clinic and Policlinic of Radiology
Martin-Luther University Halle-Wittenberg, Germany
Conflicts of interest
Scientific grants:Siemens, Phillips, ab medica, ev3/covidien/medtronic, itm Flowmedical, Toshiba, Cook, W. L. Gore
Lectures: ev3/covidien/medtronic, Biotronic, St Jude Medical, Abbott, Siemens, ab medica, Boston Scientific, itm Flowmedical, Terumo, W. L. Gore
Consulting:1st WITiG, itm Flowmedical, Siemens, ev3/covidien/medtronic, ab medica
Proctoring:W. L. Gore, ev3/covidien/medtronic, ab medica
Clinical „classification“ according to Schobinger
• Grade 1 („quiescent“)– Asymptomatic and silent, no progression
• Grade 2 („proliferating“)– Progressive swelling, some pain + symptoms
• Grade 3 („destructive“)– Pain, ischaemia, no-healing wounds, bleeding, skin
infiltration
• Grade 4 („cardiac symptoms“)– High-output cardiac failure, arrhythmia,
angina pectoris (higher age)
Angiographic classification of AVM
Type I Arterio-venous fistula Up to 3 direct fistulas withoutcircumscribed nidus
Type II Arteriolo-venousMalformation
Many feeding arteries and onedominant draining vein(DOV = dominant outflow vein)
Type IIIa Arteriolo-venulousMalformation
Non-dilated, microfistulous Nidus
Type IIIb Arteriolo-venulousMalformation
Dilated Nidus
DOV
Cho et al. J Enodvasc Ther 2006;13:527–538 Uller Wibke, Müller-Wille René, Wohlgemuth Walter A. Diagnostik und Klassifikation von Gefäßmalformationen. Interventionelle Radiologie Scan 2013; 3: 235-248
Type I
Arterio-venous fistula
Type I
DOV
A V
Arteriolo-venous Malformation with DOV
Type II
Type IIIa
Arteriolo-venulous Malformation(microfistulous with non-dilated drainage)
Type IIIb
Arteriolo-venulous Malformation(dilated drainage)
A V
Gelfoam
Liquid agents: deep tissue penetration
Vessel Lumen
Arteries/ segmentarteries Arteries 2. u. 3. order Arterioly Capillaries
Ethanol
NBCA/Lipiodol
Onyx
Coils
AVM embolisation agent: Ethanol
• Very effective, permanent occlusion
• Reduced visibility– Admixture of Lipiodol reduces effectivity
• Reduced controllability– Liquid with low viscosity
• Local complications– Necrosis, peripheral nerve damage
• Systemic complications– Hemolysis, impaired renal function, CNS toxicity,
pulmonary vasoconstriction, cardiovascular collaps (death)
Ethylene Vinyl Alcohol Copolymer (EVOH)
• Plastic: liquid monomer solid polymer – Onyx, Squid, (PHIL)
• Slow polymerization (diffusion of solvent DMSO)– Controlled process, central core remains liquid
– Longer procedure time, higher radiation dose
• Used material has to be DMSO compatible
• Radioopaque (micronized Tantalum / Iodine)
• Expansive
• Effective, but…– Local complications: pain, ischaemia, necrosis
– Systemic complications: Upper dose of DMSO 0.583 ml/kg bodyweight
AVM nidus is always larger than expected in DSA Complete filling needs actively injected agent
Endovascular treatment of peripheral AVM
• According to angio anatomy• Type I (AVF, e. g. pulmonary AVM/AVF in HHT) good prognosis Simple to treat (Coils, AVP)
• Type II with dominant venous outflow good prognosis transvenous + retrograde treatment options Good long-term results when venous outflow occluded Onyx (or Ethanol), as adjunct: coils/AVP for flow-modulation
• Type III, diffuse, net-like „Nidus“, multiple venous drainages doubious Direct puncture, i.a., i.v. Difficult to treat, high complication rate (C2H5OH) Onyx firstline, „finishing“ or recurrence alcoholmTOR-Inhibitors (?) Often more palliative option
• Wrong technique worsens situation (PVA, ligation etc.) !
Wohlgemuth Walter A, Ostertag Peter, Uller Wibke. Möglichkeiten und Grenzen moderner Embolisationsverfahren. HNO 2014; 62: 30-34
Wohlgemuth Walter A, Müller-Wille René, Teusch Veronika, Dudeck Oliver, Cahill Anne Marie, Alomari Ahmad, Uller Wibke. The retrograde transvenous push-through method: a novel treatment of peripheral arteriovenous malformations with dominant venous outflow. Cardiovasc Intervent Radiol 2015; 38: 623-631
Univ.-Prof. Dr. Dr. Walter A. Wohlgemuth1) University Clinic and Policlinic of Radiology, Martin-Luther University Halle-Wittenberg, Germany
2) German Interdisciplinary Society of Vascular Anomalies
Thank you for your attention!
Endovascular treatment ofarterio-venous malformations:
effectiveness and safety
LINC 2018
Leipzig, Germany, 31. Jan 2018
Walter A. Wohlgemuth
University Clinic and Policlinic of Radiology
Martin-Luther University Halle-Wittenberg, Germany