Endovascular management of complex vascular malformations

1. ENDOVASCULAR MANAGEMENT OF
COMPLEX VASCULAR
MALFORMATIONS
Prof. Furuzan Numan, M.D
Chief of Interventional Radiology Department
Istanbul University
Cerrahpasa School of Medicine
ISTANBUL,TURKEY 2013
ASVS&ASVF

2. VMs
• Arterio-venous malformations (AVMs) (CVMs)
• birth defects which involve the arterial and venous
vessels ,
• direct communications between the different size
vessels
• dysplastic minute vessels( a meshwork of primitive
reticular networks) which have failed to mature to
become 'capillary'
• Create the ”NIDUS".

3. VMs
• Shunting through the fistulous structures(AVF)
with high velocity, low resistance flow from
the arterial vasculature into the venous system.
• AVFs result in significant anatomical,
pathophysiological and hemodynamic
consequences.

4. VMs
• Systematic classifications such as (Hamburg
classification, ISSVA classification, Schobinger
classification, angiographic classification of
AVMs)
• help us to understand the biology and natural
history of these lesions and improved
management.

5. Modified Hamburg Classification

6. Updated ISSVA Classification

7. DIAGNOSIS
• Duplex ultrasound,CDUS,
• Magnetic resonance imaging (MRI),
• MR angiography (MRA),
• Computerized tomography (CT) and
• CT angiography (CTA).

8. DIAGNOSIS
• Arteriography (DSA) is the gold standard for
• diagnosis ,
• treatment

9. VMs
• A multidisciplinary team is necessary to
integrate surgical and non-surgical
interventions for optimum care.

10. TREATMENT
• Surgery ?
• Endovascular?

11. INDICATIONS of ENDOVASCULAR
TREATMENT
• congestive heart failure at high flow VM’s
having AVF components results of previous
surgery/s or diagnostic biyopsy.
• relief the pain
• functional disorders of extremities and joints
• cosmetic problems

12. VM’s
Ideal embolic agent should be;
• easily controlled during injection
• able to penetrate & occlude the abnormal
foci(nidus) of vascular communications in
VM’s
• provide permanent occlusion

13. VMs
An IDEAL EMBOLIC AGENT should match
MORPHOLOGY & HEMODYNAMIC status of
VMs
Structure of the Nidus

14. WHICH EMBOLIC AGENT
IS IDEAL?
Detachable Coils,
Amplatzer Plugs,
Polyvinilalcohol(PVA),
Ethanol,
N-ButrylCyanoacrylate( Glue),
Onyx

15. DETACHABLE COILS ,AMPLATZER PLUG
• Proximal occlusion of the VM’s
• No penetration to the foci
• prevent future endovascular access to the
lesions via the arterial route
VM’s

17. VM’s
PVA;
• Difficult to determine appropriate size
• Have risk of pulmonary embolism
• Usually arrested at precapillary level
• Recanalized after 2-3 weeks

18. VM’s
ETHANOL;
• Direct toxic effect on endothelium causes
coagulation & thrombosis
• Non-target embolization may occur via
transcatheter use
• Nerve damage
Disadvantage of large amounts of ethanol causes;
• CNS depression
• Hemolysis
• Cardiac arrest

22. VM’s
Acrylic polymers (N-BCA) (GLUE)
Polymerizes with blood or other ionic fluids
• Causes exothermic reaction
• Destroys vessel wall
Disadvantages due to rapid polymerization;
• Precise & safe occlusion is difficult
• High risk of adhesion of the microcatheter to the
vessel wall
• Microcatheter is out of use after each injection

23. ONYX
Biocompatible liquid embolic agent consists of;
• ETHYLENE VINYL ALCOHOL COPOLYMER
dissolved in various concentrations of
DIMETHYL SULFOXIDE (DMSO)
• TANTALUM powder

24. ONYX
DMSO causes in situ;
• PRECIPITATION & SOLIDIFICATION of the polymer forms the
ELASTIC SPONGY EMBOLUS has NO ADHESIVE effect to the
wall

25. BARDeV3

27. ONYX Injection technique
• Co-axial system:Catheter(4F), microcatheter
& microguidewire
ev3 Inc- Confidential Information CR00031 Jun/08
Onyx Delivery Systems
Marathon
And
UltraFlow
Flow-directed
Microcatheters
Rebar
Microcatheters
Mirage,
X-pedion,
SilverSpeed
Guidewires

28. ONYX injection
( Plug and Push )technique
• Flushing microcatheter with saline solution is required
• 0.4 ml dead space of microcatheter should be filled with
DMSO
• 1 ml ONYX aspirated into syringe
• 0.25 ml of the amount injected during 40 seconds until
to fill & replace DMSO in the microcatheter
• ONYX was injected at a volume & rate enough to
prevent reflux but cause enough penetration as distally
as possible under fluoroscopic guidance

29. At modified injection technique
• ONYX to penetrate more distally than microcatheter
had riched,
• and makes to use the microcatheter(and
macrocatheter) more than once which saves time &
money
• rare gluing to the arterial wall
• longer injection time & more controlled embolization
• per-embolization angiography can be performed with
the same microcatheter
• Minimizing the reflux
Flushing microcatheter lumen with DMSO helps;

30. COMPLICATIONS
• DMSO related vasospasm
• main artery occlusion
• bullous form of skin burns due to non-target
embolization
• microcatheter tip adhesion
• pulmonary embolism
• venous reflux

31. Skin burns result
of non-target
embolization

33. THE REASON of
REFLUX & NON-TARGET
EMBOLIZATION
• inefficiency of the test injection due to viscosity
differences between Onyx & contrast media
• complex and unpredictable angiostructure
of VMs
• short arterial feeders close to the parent arteries
• poor radioopacity due to concentration

35. MANEUVERS to prevent REFLUX in
high-flow VMs
• external compression to stagnate the flow
• use of high concentration of copolymer
• controlled and slow injection

36. DISADVANTAGES
• GENERAL ANESTHESIA procedure is painful
• DMSO cause the PAIN
• GARLIC LIKE smell of breath
• PRICE
• NEED OF EXTRA SESSIONS

37. 37/F R Shoulder,pain swelling

38. 32 year old man,suffers
upper left chest
mass&limitation of
effort

39. 27 y Female Left upper
extremity surgery.Pain,
swelling, varicosity,
discoloration, thrill, congestive
heart failure

40. MR Color-Doppler US
30 y female, Previous surgery, High-
flow VM of the right forearm

41. Right upper
extremity ,forearm
AVM
31 y,Female

42. S.A. 33-years-old male, right gluteal local VM. Pain, limitation of
movement, swollen of the extremity with effort.

43. Pre-embolization Post-embolization

44. 18-y Male, right gluteal local low-flow VM
Pain, swelling & varicosity
Pre-embolization Post-embolization

45. Acute Bleeding of
Uterine AVM
23 year old female

46. Acute Bleeding of Uterine AVM
23 year old female

47. Right upper
extremity diffuse
Hemangioma
21 y Male

48. Right lower extremity diffuse
Hemangioma,between age of
16-20 ,Female
3 sessions

49. AVM,18y Female
Previously embolized
Location: basis of left foot, metacarpal
area
Origin: Lateral and medial plantar
branches of posterior tibial artery

50. NOTES TO TAKE HOME
• Do not take the chance of being treated
endovascularly from these desparate patients,
• by using Amplatz Plugs,Coils ,
• ligating main(feeding)arteries surgicaly