Presentation on theme: "Scott L. Stevens, M.D. & Mark A. Farber, M.D."— Presentation transcript:
1 Scott L. Stevens, M.D. & Mark A. Farber, M.D. Postgraduate Course:Venous EndovascularCourse Directors:Scott L. Stevens, M.D. & Mark A. Farber, M.D.
2 IntroductionKim Hansen, MDWFU School of MedicineWinston-Salem, NC
3 Arteriovenous Malformations. Alan B. Lumsden, Chairman Cardiovascular SurgeryHouston, Texas
4 Vascular Lesion Treatment Arteriovenous Malformation (AVM)Definition - Congenital lesionAbnormal arteriovenous communicationsFeeding arteriesNidusOutflow veinsSymptomsSignificant shunting / CV compromisePain, neuromuscular dysfunction, tissue ulcerationHemorrhageAn arteriovenous malformation or AVM is a congenital – often deep – lesion. 8Anatomically, an AVM is comprised of many abnormal communications between adjacent arteries and veins. Feeding arteries lead to this tangled web of dilated vessels – the AVM nidus – while veins provide for outflow. 8Symptoms of an AVM are dependent upon its size and location. A large AVM produces significant shunting and can lead to cardiovascular compromise. With the local disruption in blood flow, symptoms such as pain, neuromuscular dysfunction or tissue ulceration can occur. AVM rupture results in hemorrhage.
6 Treatment Conservative Stockings Limb elevation Surgery 10% lesions Best after embolization100% success when amenable for resection
7 Vascular Lesion Treatment AVM EmbolizationEffective therapyDestruction of the nidusProcedural requirementsSuperselective access to feeding arteryInjection non-resorbable embolicagent into the nidusTherapeutic vascular embolization may provide effective therapy for AVMs. However, unlike other embolization procedures which focus on either proximal or distal arterial embolization… 8the goal of AVM embolization is destruction of the nidus. Embolization of a feeding artery would merely shift blood supply to an adjacent artery, and the AVM would remain. 8However, superselective access to the feeding artery and injection of a non-resorbable embolic agent into the nidus may produce durable occlusion. 8Embolic agents used for AVM embolization include PVA particles and microspheres, coils, absolute ethanol and n-BCA.Contour PVA particles / Contour-SE microspheresAbsolute ethanoln-BCA.014”/.035” Coils (Vortx-18 or Vortx-35)
8 Present understanding phases vascular development. EmbryologyStage I Undifferentiated: primitive blood lakes, capillary networks, no veins or arteriesStage II Retiform: Capillaries form large plexiform structuresStage III Maturation:Mature vascular channels
17 Treatment Embolization Multiple sessions Long-term commitment Usually under general anesthesiaSome report 79% success with 20% complications
18 Steps for safe embolization Good preliminary angiographyThink about collateral pathwaysUse shortest straightest approach, especially when coils usedStable catheter position and verify:Wire if using coilsContrast if soluble agentUse non-heparinized saline to flush and dilute contrastContinuous fluoro during embolizationIntermittent runs to evaluate flow
19 Vascular Lesion Treatment AVM Embolization HazardsNon-Target Distal embolic embolizationVenous outflow vessels pulmonary circulationPotentially fatal PE (Pulmonary Embolism)PreventionProper sizing of PVA microspheres / particlesImpact within the nidusCareful injection of liquid embolicsContain effects within nidusProper sizing of coilsReduce risk of displacement
21 Non-resorbable Embolic Agents: Liquid Embolic Agent n-Butyl Cyanoacrylate (n-BCA)DescriptionTissue adhesive or “glue”Treatment of cerebral AVMsMechanism of actionPolymerization upon contact with ionic fluidsFormation of a solid cast within the vesselVessel occlusionTechniqueCoaxial deliveryFlushing with non-ionic dextrose solutionImmediate catheter withdrawal
22 AVM dorsum left handDraining vein puncturedTourniquet above arterial pressure2.5cc absolute ETOH via 3Fr catheter
23 Radial Head AVM, multiple vessels feeding venous component. Catheter inserted into draining vein.Absolute alcohol injected in 4 stages.Venogram at 6 months - ablation of veins
24 Early Polymerization n-BCA adherent to tip at risk for embolus TRUFILL ® n-BCA mixture solidifies:In the microcatheter - catheter occlusionIn the AVM before the desired depth of penetration within a feeding pedicleAt the microcatheter tipn-BCA adherent to tip at risk for embolusn-BCA adherent to tip at risk for catheter retentionReflux, polymerization of non-target vesselComplications:IschemiaAVM or vessel rupture
25 Conclusion: AVM Treatment These patients lack a homeVascular Surgeons see most of AVM,sNo single therapeutic optionNeed broad oversightEmerging advanced endovascular skills in vascular surgery communityRapid growth of excellent imagingMEN -1 of vascular surgery: patient for lifeResearch- clinical- teaching opportunities
26 TRUFILL® Tantalum Powder Finely ground, irregularly shaped, dark gray metalUsed with TRUFILL ® Ethiodized Oil to radiopacify TRUFILL n-BCA liquid embolic agentMix tantalum with TRUFILL ® Ethiodized Oil prior to mixing with TRUFILL ® n-BCADO NOT use TRUFILL ® Tantalum Powder alone as a radiopacifying agent for n-BCA
27 TRUFILL® Ethiodized Oil Straw to amber colored oily fluidContains 37% iodine organically combined w/ poppyseed oil’s ethyl esters of fatty acidsInjectable, radiopaque agent to be used with n-BCA Liquid Embolic System to control polymerizationDO NOT use TRUFILL ® Ethiodized Oil alone as a diagnostic agent
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