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