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transvenous_embolization

Transvenous embolization

Transvenous embolization is a developing concept for curative therapy of cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistula.

With increasing experience and technological advances, transvenous embolization has become the treatment of choice since the 1990s for carotid cavernous fistula (CCF). Today, the venous drainage of CCFs is of greater importance for the management of these lesions and has to be a key component of any contemporary classification system 1) 2) 3).

The transvenous approach in treating vascular malformations was popularized by successful treatment models for dural arteriovenous fistulas. More recently, high-flow intracranial AVMs are being managed with transvenous endovascular approaches, although this novel technique has its challenges and perils 4).

Case series

2016

A cohort of 7 pediatric patients (younger than 18 years of age) who underwent the TVA for cerebral AVMs between January 2012 and January 2014. The TVA was used alone or in conjunction with other arterial approaches in definitive embolization sessions. Patient demographics, AVM characteristics, clinical outcomes, and angiographic results were independently assessed. Pial arteriovenous fistulae and vein of Galen malformations were excluded. Control angiograms were obtained at 6 months, and curative treatment was determined by the anatomic obliteration of the nidus.

All patients had anatomic exclusion of the AVM. The mean size was 2 ± 0.6 cm, and hemorrhage was the most common presentation (100%, n = 7). Most AVMs were deeply placed (71%, n = 5), and a proximal approach to the nidus was achieved in all cases. Transvenous embolization alone was performed in 3 patients (43%), whereas combined arterial and venous embolization was required in 4 patients (57%). The mean follow-up period was 20.2 ± 10.5 months. There were no hemorrhagic or thromboembolic events, and venous infarction was not documented. No recurrence was documented 5).

2012

Five patients underwent combined transarterial and transvenous embolization of their Vein of Galen malformation (VGAM) during the study period. VGAMs were classified based on angioarchitecture as either choroidal (1/5) or mural (4/5) according to the classification scheme of Lasjaunias. In total, 13 embolization procedures were performed consisting of 1 to 3 treatment stages per patient. Complete or near complete occlusion was achieved in 4 patients, while subtotal occlusion was achieved in 1 patient. During follow-up (median 62.6 mo), all patients were either unchanged or cognitively and neurologically intact.

VGAM can be safely and effectively treated by staged transarterial and transvenous embolization. Using this strategy, excellent long-term cognitive and functional outcomes can be achieved 6).

Case reports

Transvenous embolization (TE) has been increasingly applied for arteriovenous malformation (AVM) treatment. Transient cardiac standstill (TCS) has been described in cerebrovascular surgery but is uncommon for endovascular embolization. Rangel-Castilla et al., presented a patient with a ruptured thalamic AVM in whom both techniques were applied simultaneously. Surgery was considered, but the patient refused. Transarterial embolization was performed with an incomplete result. The deep-seated draining vein provided sole access to the AVM. A microcatheter was advanced into the draining vein. Under TCS, achieved with rapid ventricular pacing, complete AVM embolization was obtained. One-year magnetic resonance imaging and cerebral angiography demonstrated no residual AVM.The video can be found here: https://youtu.be/CAzb9md_xBU

7).

References

1)
Satomi J, Satoh K, Matsubara S, Nakajima N, Nagahiro S. Angiographic changes in venous drainage of cavernous sinus dural arteriovenous fistulae after palliative transarterial embolization or observational management: a proposed stage classification. Neurosurgery. 2005;56(3):494–502; discussion 494-502.
2)
Stiebel-Kalish H, Setton A, Nimii Y, et al.. Cavernous sinus dural arteriovenous malformations: patterns of venous drainage are related to clinical signs and symptoms. Ophthalmology. 2002;109(9):1685–1691.
3)
Suh DC, Lee JH, Kim SJ, et al.. New concept in cavernous sinus dural arteriovenous fistula: correlation with presenting symptom and venous drainage patterns. Stroke. 2005;36(6):1134–1139.
4)
Choudhri O, Ivan M, Lawton MT. Transvenous Approach to Intracranial Arteriovenous Malformations: Challenging the Axioms of Arteriovenous Malformation Therapy? Neurosurgery. 2015 Jun 26. [Epub ahead of print] PubMed PMID: 26120797.
5)
Mendes GA, Iosif C, Silveira EP, Waihrich E, Saleme S, Mounayer C. Transvenous Embolization in Pediatric Plexiform Arteriovenous Malformations. Neurosurgery. 2016 Mar;78(3):458-65. doi: 10.1227/NEU.0000000000001057. PubMed PMID: 26457485.
6)
Ellis JA, Orr L, Ii PC, Anderson RC, Feldstein NA, Meyers PM. Cognitive and functional status after vein of Galen aneurysmal malformation endovascular occlusion. World J Radiol. 2012 Mar 28;4(3):83-9. doi: 10.4329/wjr.v4.i3.83. PubMed PMID: 22468188; PubMed Central PMCID: PMC3314932.
7)
Rangel-Castilla L, Shallwani H, Siddiqui AH. Transvenous embolization of thalamic arteriovenous malformation under transient cardiac standstill. Neurosurg Focus. 2019 Jan 1;46(Suppl_1):V10. doi: 10.3171/2019.1.FocusVid.18416. PubMed PMID: 30611173.
transvenous_embolization.txt · Last modified: 2019/01/06 22:32 by administrador