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Postgraduate Course: Venous Endovascular Course Directors: Scott L. Stevens, M.D. & Mark A. Farber, M.D.

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Presentation on theme: "Postgraduate Course: Venous Endovascular Course Directors: Scott L. Stevens, M.D. & Mark A. Farber, M.D."— Presentation transcript:

1 Postgraduate Course: Venous Endovascular Course Directors: Scott L. Stevens, M.D. & Mark A. Farber, M.D.

2 Introduction Kim Hansen, MD WFU School of Medicine Winston-Salem, NC

3 Arteriovenous Malformations. Alan B. Lumsden, Chairman Cardiovascular Surgery Houston, Texas

4 Vascular Lesion Treatment Arteriovenous Malformation (AVM) Definition - Congenital lesion Abnormal arteriovenous communications Feeding arteries Nidus Outflow veins Symptoms Significant shunting / CV compromise Pain, neuromuscular dysfunction, tissue ulceration Hemorrhage

5 Treatment Absolute indications Hemorrhage Ischemia (steal) Refractory ulceration Congestive heart failure Relative indications Disabling pain Claudication Functional impairment

6 Treatment Conservative Stockings Limb elevation Surgery 10% lesions Best after embolization 100% success when amenable for resection

7 Vascular Lesion Treatment AVM Embolization Effective therapy Destruction of the nidus Procedural requirements Superselective access to feeding artery Injection non-resorbable embolic agent into the nidus Contour PVA particles / Contour-SE microspheres Absolute ethanol n-BCA.014”/.035” Coils (Vortx-18 or Vortx-35)

8 Present understanding phases vascular development. Embryology Stage I Undifferentiated: primitive blood lakes, capillary networks, no veins or arteries Stage II Retiform: Capillaries form large plexiform structures Stage III Maturation: Mature vascular channels

9

10 MRI Classification

11 What do we really need to know? Location: subcutaneous deep to fascia both Proximity to major structures sciatic nerve rectum Localized or diffuse Arterial or venous relative contribution

12 towel roll

13 head foot rectus femoris tensor fascia lata femoral nerve branches

14 venous connection

15 femur joint capsule

16

17 Treatment Embolization Multiple sessions Long-term commitment Usually under general anesthesia Some report 79% success with 20% complications

18 Steps for safe embolization Good preliminary angiography Think about collateral pathways Use shortest straightest approach, especially when coils used Stable catheter position and verify: Wire if using coils Contrast if soluble agent Use non-heparinized saline to flush and dilute contrast Continuous fluoro during embolization Intermittent runs to evaluate flow

19 Vascular Lesion Treatment AVM Embolization Hazards Non-Target Distal embolic embolization Venous outflow vessels pulmonary circulation Potentially fatal PE (Pulmonary Embolism) Prevention Proper sizing of PVA microspheres / particles Impact within the nidus Careful injection of liquid embolics Contain effects within nidus Proper sizing of coils Reduce risk of displacement

20

21 n-Butyl Cyanoacrylate (n-BCA) Description Tissue adhesive or “glue” Treatment of cerebral AVMs Mechanism of action Polymerization upon contact with ionic fluids Formation of a solid cast within the vessel Vessel occlusion – Technique Coaxial delivery Flushing with non-ionic dextrose solution Immediate catheter withdrawal Non-resorbable Embolic Agents: Liquid Embolic Agent

22 AVM dorsum left hand Draining vein punctured Tourniquet above arterial pressure 2.5cc 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 ® TRUFILL ® n-BCA mixture solidifies:  In the microcatheter - catheter occlusion  In the AVM before the desired depth of penetration within a feeding pedicle  At the microcatheter tip n-BCA adherent to tip at risk for embolus n-BCA adherent to tip at risk for catheter retention Early Polymerization  Reflux, polymerization of non-target vessel  Complications: Ischemia AVM or vessel rupture

25 Conclusion: AVM Treatment These patients lack a home Vascular Surgeons see most of AVM,s No single therapeutic option Need broad oversight Emerging advanced endovascular skills in vascular surgery community Rapid growth of excellent imaging MEN -1 of vascular surgery: patient for life Research- clinical- teaching opportunities

26 Finely ground, irregularly shaped, dark gray metal ® Used with TRUFILL ® Ethiodized Oil to radiopacify TRUFILL n-BCA liquid embolic agent ® ® Mix tantalum with TRUFILL ® Ethiodized Oil prior to mixing with TRUFILL ® n-BCA ® DO NOT use TRUFILL ® Tantalum Powder alone as a radiopacifying agent for n-BCA TRUFILL ® Tantalum Powder

27 TRUFILL ® Ethiodized Oil Straw to amber colored oily fluid Contains 37% iodine organically combined w/ poppyseed oil’s ethyl esters of fatty acids Injectable, radiopaque agent to be used with n-BCA Liquid Embolic System to control polymerization ® DO NOT use TRUFILL ® Ethiodized Oil alone as a diagnostic agent

28 Inject TRUFILL ® Ethiodized Oil into sterile beaker TRUFILL ® n-BCA Procedure Set-up

29 Add TRUFILL Tantalum Powder to sterile beaker TRUFILL ® n-BCA Procedure Set-up

30 Mix TRUFILL Ethiodized Oil and TRUFILL Tantalum Powder TRUFILL ® n-BCA Procedure Set-up

31 Attach self-piercing cap to the syringe; then attach to the TRUFILL n-BCA vial TRUFILL ® n-BCA Procedure Set-up

32 Aspirate TRUFILL n-BCA into syringe TRUFILL ® n-BCA Procedure Set-up

33 Add TRUFILL n-BCA to mixture in beaker and mix thoroughly TRUFILL ® n-BCA Procedure Set-up

34 Rinse microcatheter hub with syringe of D5W TRUFILL ® n-BCA Procedure Set-up

35 Flush microcatheter with D5W TRUFILL ® n-BCA Procedure Set-up

36 Aspirate TRUFILL n-BCA mixture into syringe; Compare mixture-filled syringe with contrast-filled syringe under fluoroscopy TRUFILL ® n-BCA Procedure Set-up

37 Inject TRUFILL n-BCA mixture through microcatheter TRUFILL ® n-BCA Procedure Set-up

38 Microcatheters TRUFILL ® n-BCA is compatible with: PROWLER ® Microcatheter family. PROWLER ® Microcatheter family. PROWLER SELECT ® Microcatheter family. PROWLER SELECT ® Microcatheter family. TRANSIT ® Microcatheter family TRANSIT ® Microcatheter family RAPIDTRANSIT® Infusion catheterRAPIDTRANSIT® Infusion catheter MASSTRANSIT® Max ID catheterMASSTRANSIT® Max ID catheter TRANSIT® MicrocatheterTRANSIT® Microcatheter


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