embolization of efferent venous outflow of congenital fistula-type

EMBOLIZATON OF EFFERENT VENOUS OUTFLOW OF HIGH-FLOW FISTULA-TYPE

ARTERIOVENOUS MALFORMATONS AFTER FAILED ARTERIAL EMBOLIZATON

Matthew Krosin MDResident Radiologist; PGY-2

Robert Short MD PhDAssistant Professor of Radiology

Ernesto Santos MDDivision Chief of

Vascular & Interventional Radiology

University of Pittsburgh

Medical Center

Division of

Vascular & Interventional Radiology

GEST Oral Abstract

May 7, 2016

Matthew Krosin

• No relevant financial relationship reported

• Arteriovenous malformations (AVM)

• Conventionally arterial embolization

• Coils, glues, and particles

• Problems – New feeding arteries

– Non-target embolization

– Failure to thrombose

– Serial treatments

– Long cases

PURPOSE

–Many feeding vessels

–Large size & high flow rates

–Severe symptoms & sequelae

–Dominant venous drainage

= Venous Approach

SOME AVMs DEMONSTRATE:

• Single Center

• 3-year retrospective review

• AVM with single predominant vein

• n=4, low prevalence

• Prior arterial treatment failure (intent)

Methods

Case 1

• 53 year old male, refractory hematuria

• Large intra-pelvic AVM involving right ureter and bladder wall

Case 1

Click ImageFor Video

Case 1

Initial Treatment by another service;2008

RIGHT INTERNAL ILIAC ARTERY

Case 1

2008

Case 1

Another service, 2008

Case 1

Recurrent hematuria 3/2014

Case 1

VIR Venous Embolization 3/2014

LEFT INTERNAL ILIAC ARTERY

Case 1RIGHT INTERNAL JUGULAR ACCESS

Case 1

STASIS

TARGET

Case 13/2016: hematuria remains resolved

Case 2

• 41 year old male

• Right posterior thigh AVM

– Leg swelling

– Pain

– Sciatica

– Claudication

Case 2

R thigh AVM

1/2013

Prior to

treatment

Click ImageFor Video

Case 2

RIGHT INFERIOR GLUTEAL ARTERY

coils

Case 2

RIGHT PROFUNDA

coils

Case 2

2/2013 (1 mo) 5/2013 (4 mo.)

RIGHT INFERIOR GLUTEAL ARTERY RIGHT

PROFUNDA

n-BCAn-BCA

Case 2

11/2013 (10 mo.)

RIGHT INFERIOR GLUTEAL ARTERY

Case 2

11/2013 (10 mo.)

STASIS

Case 2

5/2014

6 mo. postVenous

Treatment

Asymptomatic

Click ImageFor Video

Case 3

• Relative of Case 2

• 14 year old female

• Painful left forearm AVM

Case 3

2/2013 Click ImageFor Video

Case 3

2/2013

BRACHIAL ARTERY

INTEROSSEOUS ARTERY

ULNAR COLLATERAL RTERY

Case 3

2/2013

Case 3

11/2013 (10 mo.)

Case 3

5/2014 Continued resolution of symptoms

Click ImageFor Video

Case 4

10/2015

• 26 year old male

• Lhermitte-Duclos

syndrome

• Painful left calf AVM

• Varicosities

Click ImageFor Video

Case 4RIGHT POPLITEALARTERY

LESSERSAPHENOUSVEIN

Case 4

10/2015

Case 4• 12/2015

(2 mo.)

• Resolution

of painful

symptoms

• Improvement

in varicosities

Click ImageFor Video

CONCLUSIONS

• Technical and Clinical success

– 4/4 (100%)

• Dominant venous efferent can be a more straightforward and/or effective means for therapy in certain AVMs

FURTHER INVESTIGATONS

• Does previous arterial devascularization aid in success of subsequent venous embolization?

• Alternative techniques to consider:

– Retrograde balloon-assisted liquids

– Vascular plugs

• More patients!!

QUESTIONS?

Albuquerque, F., Ducruet, A., Crowley, R. W., Bristol, R., Ahmed, A., & McDougall, C. (2014). Transvenous to arterial Onyx embolization.Journal of Neurointerventional Surgery, 6, 281–285. http://doi.org/10.1136/neurintsurg-2012-010628

Cho, S., Do, Y. S., Kim, D. I., Kim, Y. W., Shin, S. W., Park, K. B., … Choo, I. W. (2008). Peripheral arteriovenous malformations with a dominant outflow vein: results of ethanol embolization. Korean J Radiol, 9(3), 258–267. http://doi.org/10.33848/kjr.2008.9.3.258

Conway, A., Qato, K., Drury, J., & Rosen, R. (2015). Embolization techniques for high-flow arteriovenous malformations with a dominant outflow vein.Journal of Vascular Surgery, 3(2), 178–182.

Koganemaru, M., Abe, T., Iwamoto, R., Suenaga, M., Matsuoka, K., & Hayabuchi, N. (2012). Pelvic Arteriovenous Malformation Treated by SuperselectiveTranscatheter Venous and Arterial Embolization.Japanese Journal of Radiology, 30(6), 526–529. http://doi.org/10.1007/s11604-012-0081-8

Legiehn, G., & Heran, M. (2006). Classification, Diagnosis, and Interventional Radiologic Management of Vascular Malformations. Orthopedic Clinics of North America,37(3), 435–474. http://doi.org/10.1016/j.ocl.2006.04.005

Park, K., Do, Y., Kim, D.-I., Kim, Y., Shin, B., Park, H., … Lee, B.-B. (2012). Predictive Factors for Response of Peripheral Arteriovenous Malformations to Embolization Therapy: Analysis of Clinical Data and Imaging Findings.Journal of Vascular and Interventional Radiology,23(11), 1478–1486. http://doi.org/10.1016/j.jvir.2012.08.012

van der Linden, E., van Baalen, J., & Pattynama, P. (n.d.). Retrograde transvenous ethanol embolization of high-flow peripheral arteriovenous malformations. Cardiovasc Intervent Radiol, 35, 820–825. http://doi.org/10.1007/s00270-011-0265

Wohlgemuth, W., Muller-Wille, R., Teusch, V., Dudeck, O., Cahill, A., Alomari, A., & Uller, W. (2015). The Retrograde Transvenous Push-Through Method: A Novel Treatment of Peripheral Arteriovenous Malformations with Dominant Venous Outflow.Cardiovascular and Interventional Radiology,38(3), 623–631. http://doi.org/10.1007/s00270-015-1063-x

REFERENCES