Double Arterial Catheterization Technique for Embolization of Brain Arteriovenous Malformations With Onyx

Neurosurgery ◽  
2012 ◽  
Vol 72 (1) ◽  
pp. 92-98 ◽  
Author(s):  
Leonardo Renieri ◽  
Arturo Consoli ◽  
Giulia Scarpini ◽  
Giulia Grazzini ◽  
Sergio Nappini ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Medium Size ◽  
Endovascular Techniques ◽  
Complete Occlusion ◽  
Arterial Catheterization ◽  
Catheterization Technique ◽  
Occlusion Rate ◽  
Brain Avms ◽  
Lower Morbidity

Abstract BACKGROUND: Arteriovenous malformation (AVM) treatment is multidisciplinary, and the patient may undergo embolization, neurosurgery, or radiosurgery combined. Great improvement in endovascular techniques was provided by the introduction of Onyx with different kinds of approach. OBJECTIVE: To evaluate the efficacy and the safety of Onyx embolization of brain AVMs with the double arterial catheterization technique (DACT). METHODS: This was a retrospective study. From January 2006 until June 2011, 61 AVMs eligible for the DACT were treated. Forty-one of the 61 AVMs were treated with single arterial catheterization technique and 20 of 61 with DACT; patient age and Spetzler-Martin AVM grade were similar in the 2 groups. RESULTS: In the DACT group, we obtained complete occlusion of the nidus in all small AVMs, whereas in the single arterial catheterization technique group, we obtained complete occlusion in only 1 of the 36% of the cases. Among the medium-size AVMs, there were no significant differences in the 2 groups, but we performed fewer procedures per patient when we used the DACT (1.4 vs 2.2). In the DACT group, we observed fewer hemorrhagic complications (3.4% vs 12.5% per procedure) and lower morbidity (5% vs 7% per patient) and mortality (0% vs 2.4%) rates. CONCLUSION: The DACT in multifeeder AVMs may lead to a higher occlusion rate of the nidus for small AVMs and reduce the number of procedures, ensuring a higher standard of safety because of the possibility of managing the progression of Onyx into venous drainage.

scholarly journals Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades

2015 ◽  
Vol 122 (5) ◽  
pp. 1229-1238 ◽  
Author(s):  
Christina Iosif ◽  
Georges A. C. Mendes ◽  
Suzana Saleme ◽  
Sanita Ponomarjova ◽  
Eduardo Pedrolo Silveira ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Clinical Status ◽  
Surgical Techniques ◽  
Venous Drainage ◽  
Endovascular Embolization ◽  
Modified Rankin Scale ◽  
Transvenous Embolization ◽  
Scale Scores ◽  
Therapeutic Decision Making ◽  
Brain Avms

OBJECT Ruptured cerebral arteriovenous malformations (AVMs) with deep localization and high Spetzler-Martin grades are associated with considerable challenges regarding nidus eradication treatment. The authors report their experience with curative endovascular transvenous embolization in a series of patients harboring “untreatable” lesions. METHODS Between January 2008 and June 2013, a transvenous endovascular embolization protocol was implemented at the authors' institution for consecutive patients with ruptured brain AVMs that were considered incurable by classic endovascular and surgical techniques. Therapeutic decision making was based on Spetzler-Martin grades, AVM location, type of venous drainage, and angioarchitectural evaluation. Complete exclusion of the nidus was the objective of treatment. RESULTS Twenty patients (10 male and 10 female, mean age 36.7 ± 17.7 years) were included. Initial Spetzler-Martin grades were III–V for 90.0% of the patients. The lesions were deeply seated in 80% and in eloquent locations in 90% of cases. The preprocedural modified Rankin Scale score was 0–2 for 12 of the 20 patients (60.0%), 3 for 2 patients (10.0%), and 4 for 6 patients (30.0%). The postprocedural clinical status was unchanged for all patients. The procedure was technically feasible in all cases. Procedure-related mortality was 0%. Ninety percent of the patients were independent in their everyday lives (modified Rankin Scale Scores 0–2) at the 6-month follow-up. In all cases but one (95%) the embolization was curative, confirmed by selective DSA at 6 months and 18 months postintervention. CONCLUSIONS Single-session endovascular transvenous embolization seems to be a safe and effective curative treatment for patients harboring complex brain AVMs with high Spetzler-Martin grade.

Overview of the current concepts in the management of arteriovenous malformations of the brain

2020 ◽  
Vol 96 (1134) ◽  
pp. 212-220 ◽  
Author(s):  
AKA Unnithan
Keyword(s):  
Arteriovenous Malformations ◽  
Treatment Options ◽  
Descriptive Analysis ◽  
Randomised Trial ◽  
Surgical Techniques ◽  
Venous Drainage ◽  
Interventional Therapy ◽  
Brain Avms ◽  
Endothelial Growth Factor ◽  
The Brain

BackgroundThere is a lack of consensus in the management of arteriovenous malformations (AVMs) of the brain since ARUBA (A Randomised trial of Unruptured Brain Arteriovenous malformations) trial showed that medical management is superior to interventional therapy in patients with unruptured brain AVMs. The treatment of brain AVM is associated with significant morbidity.Objectives and methodsA review was done to determine the behaviour of brain AVMs and analyse the risks and benefits of the available treatment options. A search was done in the literature for studies on brain AVMs. Descriptive analysis was also done.ResultsThe angiogenic factors such as vascular endothelial growth factor and inflammatory cytokines are involved in the growth of AVMs. Proteinases such as matrix metalloproteinase-9 contribute to the weakening and rupture of the nidus. The risk factors for haemorrhage are prior haemorrhage, deep and infratentorial AVM location, exclusive deep venous drainage and associated aneurysms. The advancements in operating microscope and surgical techniques have facilitated microsurgery. Stereotactic radiosurgery causes progressive vessel obliteration over 2–3 years. Endovascular embolisation can be done prior to microsurgery or radiosurgery and for palliation.ConclusionsSpetzler-Martin grades I and II have low surgical risks. The AVMs located in the cerebellum, subarachnoid cisterns and pial surfaces of the brainstem can be treated surgically. Radiosurgery is preferable for deep-seated AVMs. A combination of microsurgery, embolisation and radiosurgery is recommended for deep-seated and Spetzler-Martin grade III AVMs. Observation is recommended for grades IV and V.

scholarly journals Endovascular Treatment of Brain Arteriovenous Malformations Using Onyx: Preliminary Results of a Prospective Multicenter Study

2005 ◽  
Vol 11 (1_suppl) ◽  
pp. 159-164 ◽  
Author(s):  
L. Pierot ◽  
A. C. Januel ◽  
D. Herbreteau ◽  
X. Barreau ◽  
J. Drouineau ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Clinical Value ◽  
Multicentric Study ◽  
Ethylene Vinyl Alcohol ◽  
Complete Occlusion ◽  
Preliminary Results ◽  
Liquid Polymer ◽  
Brain Arteriovenous Malformations ◽  
Permanent Occlusion ◽  
Brain Avms

The main final goal of the treatment of brain AVMs is to prevent bleeding and to obtain a complete occlusion of the nidus. The strategy of treatment of brain arteriovenous malformations (AVM) has to be defined by a multidisciplinary team and will usually combine several modalities (surgery, radiosurgery, embolization). Embolization is generally the first step of treatment. Occasionally embolization is able to completely occlude a small AVM. Otherwise embolization is the first step before surgery or radiosurgery. Several embolic agents have been proposed for embolization of brain AVMs like particles or cyanoacrylates. The main disadvantage of particles is the high frequency of recanalization. The cyanoacrylates are probably more appropriate, providing a permanent occlusion. However, due to the polymerizing characteristics of the glue, the time of injection is relatively short (few seconds or minutes) and a complete or substantial occlusion of the nidus is difficult to obtain, especially in the case of medium or largesized AVMs. Onyx is a nonadhesive liquid polymer made of a mixture of ethylene-vinyl-alcohol copolymer and dimethylsulfoxide. The theoretical advantage of a nonadhesive liquid is to eliminate the risk of gluing the microcatheter and subsequently to perform a more durable injection with a larger amounts of agent delivered in a single injection. Several French centers have undertaken a prospective, multicentric study to evaluate the clinical value of Onyx in embolization of brain AVMs. As required, 50 patients were included. Preliminary results are presented regarding the first 48 patients, the last 2 patients being included after writing of this paper. The treatment is now completed in 15 patients. As expected, it was possible with Onyx to perform long duration injections (5 to 70 minutes with a mean of 34 minutes). Volumes injected per session were also important (0.25 to 6 ml with a mean of 1.6 ml). According to the clinical experience of the centers, duration and volume injected were most important with Onyx than with cyanoacrylates. Out of the 15 patients for whom embolization is now completed, 14 had a percentage of occlusion of the nidus greater than 60% (with 2 complete occlusion).

scholarly journals Embolization of Arteriovenous Malformations Prior to Radiosurgery

2000 ◽  
Vol 6 (1_suppl) ◽  
pp. 131-137 ◽  
Author(s):  
S. Miyachi ◽  
M. Negoro ◽  
R. Okamoto ◽  
G. Otsuka ◽  
O. Suzuki ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Diffuse Type ◽  
Complete Occlusion ◽  
Occlusion Rate ◽  
Embolic Materials

Embolization prior to radiosurgery is useful to reduce the AVM nidus for adequate planning for radiosurgery. In 37 cases we encountered, patients with the least radiosurgical effects had diffuse type nidus, where the feeders embolized with absorbable embolic materials had the possibility of recanalization. The main purpose of embolization is to prevent bleeding while the radiosurgical effects are being fully obtained. Thus, nidus embolization and the occlusion of fistulous feeders, meningeal feeders and intranidal aneurysms using permanent embolic materials are essential, since effective and successful embolization can increase the occlusion rate and shorten the period until complete occlusion following radiosurgery.

Gamma Knife Radiosurgery for Incidental, Symptomatic Unruptured, and Ruptured Brain Arteriovenous Malformations

2021 ◽  
Vol 50 (2) ◽  
pp. 222-230
Author(s):  
Byung Sup Kim ◽  
Je Young Yeon ◽  
Hyung Shik Shin ◽  
Jong-Soo Kim ◽  
Seung-Chyul Hong ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Venous Drainage ◽  
Age At Diagnosis ◽  
Significant Difference ◽  
Ruptured Avm ◽  
The Mean ◽  
Risk Of Hemorrhage ◽  
Brain Avms

Background: This study was performed to investigate clinical characteristics and outcome after gamma knife radiosurgery (GKS) in patients with incidental, symptomatic unruptured, or ruptured arteriovenous malformations (AVMs). Methods: A total of 491 patients with brain AVMs treated with GKS from June 2002 to September 2017 were retrospectively reviewed. All patients were classified into the incidental (n = 105), symptomatic unruptured (n = 216), or ruptured AVM (n = 170) groups. Results: The mean age at diagnosis of incidental, symptomatic unruptured, and ruptured AVMs was 40.3, 36.7, and 27.6 years, respectively. The mean nidus volume was 3.9, 5.7, and 2.4 cm3, respectively. Deep venous drainage was identified in 34, 54, and 76% patients, respectively. There were no significant differences in obliteration rates after GKS between the 3 groups (64.8, 61.1, and 65.9%, respectively) after a mean follow-up period of 60.5 months; however, patients with incidental AVM had a significantly lower post-GKS hemorrhage rate than patients with symptomatic unruptured or ruptured AVMs (annual hemorrhage rate of 1.07, 2.87, and 2.69%; p = 0.028 and p = 0.049, respectively). Conclusions: There is a significant difference in clinical and anatomical characteristics between incidental, symptomatic unruptured, and ruptured AVMs. The obliteration rate after GKS is not significantly different between the 3 groups. Meanwhile, an older age at diagnosis and lower hemorrhage rate after GKS in incidental AVMs suggest that they have a more indolent natural course with a lower life-long risk of hemorrhage.

Cerebral arteriovenous malformations. Part 2: physiology

2009 ◽  
Vol 26 (5) ◽  
pp. E11 ◽  
Author(s):  
Parham Moftakhar ◽  
Jason S. Hauptman ◽  
Dennis Malkasian ◽  
Neil A. Martin
Keyword(s):  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Therapeutic Approaches ◽  
Complex Processes ◽  
Brain Avm ◽  
Flow Phenomena ◽  
Vascular Steal ◽  
Brain Avms ◽  
And Behavior ◽  
The Brain

ObjectThe scientific understanding of the nature of arteriovenous malformations (AVMs) in the brain is evolving. It is clear from current work that AVMs can undergo a variety of phenomena, including growth, remodeling, and/or regression—and the responsible processes are both molecular and physiological. A review of these complex processes is critical to directing future therapeutic approaches. The authors performed a comprehensive review of the literature to evaluate current information regarding the genetics, pathophysiology, and behavior of AVMs.MethodsA comprehensive literature review was conducted using PubMed to reveal the angioarchitecture and cerebral hemodynamics of AVMS as they relate to lesion development.ResultsFeeding artery pressures, brain AVM compartmentalization, venous drainage, flow phenomena, and vascular steal are discussed.ConclusionsThe dynamic nature of brain AVMs is at least in part attributable to hemodynamic and flow-related phenomena. These forces acting on an evolving structure are critical to understanding the challenges in endovascular and surgical therapy. As knowledge in this field continues to progress, the natural history and predicted behavior of these AVMs will become more clearly elucidated.

Abstract 179: Brain Avm Embolization With Onyx: Clinical And Anatomical Results In A Prospective, Multicenter, European Study (BRAVO)

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Laurent Pierot ◽  
Keyword(s):  
Arteriovenous Malformations ◽  
Multidisciplinary Approach ◽  
Interventional Neuroradiology ◽  
High Rate ◽  
First Line ◽  
Complete Occlusion ◽  
Brain Arteriovenous Malformations ◽  
Brain Avm ◽  
Long Time ◽  
Brain Avms

Purpose: The treatment of brain arteriovenous malformations (AVMs) is challenging based on a multidisciplinary approach involving neurosurgery, radiosurgery, and interventional neuroradiology. The embolization of brain AVMS was for a long time performed using particles and glue. Onyx has been recently introduced in the armamentarium for AVM embolization, but large, multicenter evaluation is lacking. BRAVO study was conducted to evaluate the clinical and anatomical results of brain AVM embolization with Onyx. Materials and Methods: BRAVO (Brain ArterioVenous malformations embolization with Onyx) was a multicentric, prospective, consecutive study conducted in 11 neurointerventional centers in Europe. 117 patients harbouring brain AVMs embolized with Onyx were included. Clinical presentation was mostly hemorrhage (30.8%) and epilepsy (27.4%). AVM size was less than 3cm in 52.1% of cases and more than 3cm in 47.9% of cases. A mean number of 2.05 embolization sessions / patient were performed with injection of a mean of 2.4 ml Onyx / session. Results: Complete occlusion was obtained with Onyx embolization alone in a high percentage of cases (23.5% of all cases and 36.7% of AVM smaller than 3cm). Intra and post-operative bleeding related to the treatment was observed in 9.4% leading to death in 3.4% and neurologic worsening in 1.7%. Non-hemorrhagic permanent deficits were observed in 6.0% of cases. Treatment related morbidity (mRS>2) and mortality were respectively 5.1% and 4.3%. Conclusion: Embolization of brain AVMs with Onyx is associated with a high rate of complete occlusion with acceptable morbidity and mortality. Onyx has to be used as the first line embolization agent for the treatment of brain AVMs.

scholarly journals Angiographic Predictors of Spontaneous Obliteration of Transarterial Partially Embolized Brain Arteriovenous Malformations.

2021 ◽  
Author(s):  
Ahmed Elsayed Sultan ◽  
Tamer Hassan ◽  
Tamer Ibrahim Metwaly
Keyword(s):  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Embolic Agent ◽  
Arterial Phase ◽  
Complete Occlusion ◽  
Complete Obliteration ◽  
Long Term Follow Up ◽  
Venous Phase ◽  
Flow Stasis

Abstract Background: spontaneous obliteration of cerebral arteriovenous malformations is uncommon but could occur after partial embolization. Materials and methods:A retrospective study of 140 patients that underwent embolization for cerebral AVMs from 2005 to August 2019 using liquid embolic agents. The angiographic outcome of patients was classified as regard complete embolization, partial embolization, and complete obliteration after partial embolization. The parameters studied included size, location, number of arterial feeders, number of draining veins, rupture status, embolic agent, and patient factors as well.Results: The study patients included 74 (53%) females and 66 (47%) males. Their age ranged from 7 to 43 years old. One hundred and eight patients (77%) presented with hemorrhage. The AVM grades were grade II in 57 (40.7%) patients and grade III in 56 (39.3%) patients. Sixty-one (43.57%) patients were treated by n-Butyl Cyanoacrylate and 71(50.71%) patients were treated with Onyx, and both materials were used together in 8 cases. Follow-up angiography was done from 6 to 36 months after embolization. The rate of complete occlusion in all patients was 61.43% (86 patients). There were three groups of patients, the first group had complete occlusion of the nidus at the time of embolization and included 68 (48.57%) patients. The second group had partial embolization with partial occlusion of the nidus 54 patients (38.57%). The 3rd group included 18 patients (12.85%) with complete nidal occlusion on follow up after partial embolization. The delay in the venous drainage of the AVM to the late arterial phase or early venous phase with flow stasis was a significant predictor of future obliteration on follow up after partial embolization. Other significant parameters that were associated with the progressive disappearance of the AVM nidus on follow up after partial embolization are presentation with hemorrhage, AVMs size less than 3 cm, the presence of single draining or double draining veins, superficial venous drainage, and one or 2 arterial feeders.Conclusion: spontaneous closure of intracranial arteriovenous malformations after partial embolization may be encountered in cases of stasis of flow during embolization procedure with a delay of the venous drainage. A long-term follow-up of more cases over many years is required to confirm the validity of this conclusion.

Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 96-101 ◽  
Author(s):  
Jong Hee Chang ◽  
Jin Woo Chang ◽  
Yong Gou Park ◽  
Sang Sup Chung
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Maximum Diameter ◽  
Content Type ◽  
Complete Occlusion ◽  
Factors Associated ◽  
Martin Grade ◽  
Fine Print

Object. The authors sought to evaluate the effects of gamma knife radiosurgery (GKS) on cerebral arteriovenous malformations (AVMs) and the factors associated with complete occlusion. Methods. A total of 301 radiosurgical procedures for 277 cerebral AVMs were performed between December 1988 and December 1999. Two hundred seventy-eight lesions in 254 patients who were treated with GKS from May 1992 to December 1999 were analyzed. Several clinical and radiological parameters were evaluated. Conclusions. The total obliteration rate for the cases with an adequate radiological follow up of more than 2 years was 78.9%. In multivariate analysis, maximum diameter, angiographically delineated shape of the AVM nidus, and the number of draining veins significantly influenced the result of radiosurgery. In addition, margin radiation dose, Spetzler—Martin grade, and the flow pattern of the AVM nidus also had some influence on the outcome. In addition to the size, topography, and radiosurgical parameters of AVMs, it would seem to be necessary to consider the angioarchitectural and hemodynamic aspects to select proper candidates for radiosurgery.

scholarly journals Techniques of Onyx Embolization of Arteriovenous Malformation: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kathryn M Wagner ◽  
Visish M Srinivasan ◽  
Peter Kan
Keyword(s):  
Informed Consent ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Great Care ◽  
Endovascular Techniques ◽  
Definitive Therapy ◽  
Feeding Vessels ◽  
Multiple Feeding ◽  
Staged Treatment

Abstract Advances in endovascular techniques and tools have allowed for treatment of complex arteriovenous malformations (AVMs), which historically may have posed unacceptable risk for open surgical resection. Endovascular treatment may be employed as an adjunct to surgical resection or as definitive therapy. Improvements in embolization materials have made endovascular AVM treatment safer for patients and useful across a variety of lesions. While many techniques are employed for transarterial AVM embolization, the essential tenets apply to all procedures: (1) great care should be taken to cannulate only vessels directly supplying the lesion, and not en passage vessels, prior to injecting embolisate; (2) embolisate should travel into the nidus, but not into the draining veins; (3) embolistate reflux proximal to the microcatheter should be avoided. There are several techniques that accomplish these goals, including the plug and push method, or using a balloon to prevent embolisate reflux. We use controlled injection of liquid Onyx (Medtronic), with increasing pressure over multiple injections pushing the embolisate forward into the AVM. This is repeated in multiple feeding vessels to decrease or eliminate supply to the AVM. Here, we present a 36-yr-old female with a right parietal AVM discovered on workup of headaches. After informed consent was obtained, she underwent preoperative embolization using this technique prior to uncomplicated surgical resection. The video shows the endovascular Onyx embolization of multiple feeding vessels over staged treatment.

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