embolization of efferent venous outflow of congenital fistula-type
TRANSCRIPT
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
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