Skip to main content
SpringerLink
Log in

Interventional treatment of arterio-venous malformations

Interventionelle Behandlung von arteriovenösen Fehlbildungen

  • Leitthema
  • Published:
Gefässchirurgie Aims and scope Submit manuscript

Abstract

Background

Due to their hemodynamic effects and tendency to progress, the majority of congenital arterio-venous malformations (AVM) require treatment. AVM are classified according to clinical severity (Schobinger classification, stages I–V) and angiographic appearance (types I–IV).

Treatment

Endovascular embolization is the treatment of choice. However, because complications such as necrosis and neuropathy occur in up to 15% of cases, treatment is challenging and is dependent on the angiographic appearance. Critical for treatment success is elimination of the so-called nidus, which is the location of the short circuit connection between the artery and the often extended aneurysm-like drainage vein. Embolization of only the feeding artery without the actual nidus or the incomplete elimination of drainage veins should be avoided. Absolute 96 % alcohol in addition to coiling of the nidus has been established as the most effective technique.

Conclusion

Unlike other embolic agents, alcohol leads to a definitive destruction of the vessel wall. Recanalization and recurrence are excluded due to adequate elimination of the nidus.

Zusammenfassung

Hintergrund

Angeborene arteriovenöse Malformationen (AVM) stellen aufgrund ihrer hämodynamischen Auswirkungen und Progressionstendenz mehrheitlich eine Therapieindikation dar. AVM werden nach ihrem klinischen Schweregrad (Schobinger-Klassifikation, Stadium I–V) und ihrem angiographischen Erscheinungsbild (Typ I–IV) eingeteilt.

Behandlung

Therapie der Wahl ist die kathetertechnische Embolisation wobei die Behandlung aufgrund der hohen Komplikationsraten mit Nekrosen und Neuropathien in bis zu 15 % der Fälle anspruchsvoll ist, und sich die Technik nach dem angiographischen Erscheinungsbild richtet. Entscheidend für den Therapieerfolg ist die Ausschaltung des sog. „Nidus“, der den Ort der Kurzschlussverbindung zwischen der Arterie und der oft aneurysmartisch erweiterten Drainagevene darstellt. Zu vermeiden ist die alleinige Embolisation der zuführenden Arterie ohne den eigentlichen Nidus zu erreichen oder die inkomplette Ausschaltung von Drainagevenen. Absoluter 96 %-iger Alkohol in Verbindung mit einem Coiling des Nidus ist als die effektivste Technik etabliert.

Schlussfolgerung

Im Gegensatz zu anderen Embolisaten führt Alkohol zu einer definitiven Zerstörung der Gefäßwand, wodurch eine Rekanalisation und ein Auftreten eines Rezidivs bei adäquater Ausschaltung des Nidus ausgeschlossen ist.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Lee BB, Baumgartner I, Berlien HP et al (2013) Consensus document of the International Union of Angiology (IUA)-2013 current concepts on the management of arterio-venous malformations. Int Angiol 32:9–36

    CAS  PubMed  Google Scholar 

  2. Tasnadi G (1993) Epidemiology and etiology of congenital vascular malformations. Semin Vasc Surg 6:200–203

    CAS  PubMed  Google Scholar 

  3. Houdart E, Gobin YP, Casasco A et al (1993) A proposed angiographic classification of intracranial arteriovenous fistulae and malformations. Neuroradiology 35:381–385

    Article  CAS  PubMed  Google Scholar 

  4. Do YS, Park KB, Cho SK (2007) How do we treat arteriovenous malformations (tips and tricks)? Tech Vasc Interv Radiol 10:291–298

    Article  PubMed  Google Scholar 

  5. Cho SK, Do YS, Shin SW et al (2006) Arteriovenous malformations of the body and extremities: analysis of therapeutic outcomes and approaches according to a modified angiographic classification. J Endovasc Ther 13:527–538

    Article  PubMed  Google Scholar 

  6. Yakes WF, Yakes AM (2014) Yakes classification of high flow AVMS and its therapeutic implications. In: Mattassi R, Loose D, Vaghi M (eds) Atlas of hemagiomas and vascular malformations, 2nd edn. Springer-Verlag, Milan (in press)

  7. Cho SK, Do YS, Kim DI et al (2008) Peripheral arteriovenous malformations with a dominant outflow vein: results of ethanol embolization. Korean J Radiol 9:258–267

    Article  PubMed Central  PubMed  Google Scholar 

  8. Burrows P (2008) Endovascular treatment of vascular malformations of the female pelvis. Semin Intervent Radiol 25:347–360

    Article  PubMed Central  PubMed  Google Scholar 

  9. Fan XD, Su LX, Zheng JW et al (2009) Ethanol embolization of arteriovenous malformations of the mandible. AJNR Am J Neuroradiol 30:1178–1183

    Article  CAS  PubMed  Google Scholar 

  10. Numan F, Omeroglu A, Kara B et al (2004) Embolization of peripheral vascular malformations with ethylene vinyl alcohol copolymer (Onyx). J Vasc Interv Radiol 15:939–946

    Article  PubMed  Google Scholar 

  11. Widlus DM, Murray RR, White RI Jr et al (1988) Congenital arteriovenous malformations: tailored embolotherapy. Radiology 169:511–516

    Article  CAS  PubMed  Google Scholar 

  12. Rao VRK, Mandalan KR, Gupta AK et al (1989) Dissolution of isobutyl 2-cyanoacrylate on Long Term Follow-up. AJNR Am J Neuroradiol 10:135–141

    CAS  PubMed  Google Scholar 

  13. Jacobowitz GR, Rosen RJ, Rockman CB et al (2001) Transcatheter embolization of complex pelvic vascular malformations: results and long-term follow-up. J Vasc Surg 33:51–55

    Article  CAS  PubMed  Google Scholar 

  14. Cohen JE, Gomori JM, Grigoriadis S et al (2009) Complete and persistent occlusion of arteriovenous malformations of the mandible after endovascular embolization. Neurol Res 31:467–471

    Article  PubMed  Google Scholar 

  15. Grady RM, Sharkey AM, Bridges ND (1994) Transcatheter coil embolisation of a pulmonary arteriovenous malformation in a neonate. Br Heart J 71:370–371

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  16. Novak D (1990) Embolization materials. In: Dondelinger RF, Rossi P, Kurdziel JC, Wallace S (eds) Interventional radiology. Thieme, New York, pp 295–313

  17. Weber J (1987) Embolisationstherapie arteriovenöser Missbildungen. Radiol Diagn 28:513–516

    CAS  Google Scholar 

  18. Cohen JE, Gomori JM, Grigoriadis S et al (2009) Complete and persistent occlusion of arteriovenous malformations of the mandible after endovascular embolization. Neurol Res 31:467–471

    Article  PubMed  Google Scholar 

  19. Gianturco C, Anderson JH, Wallace S (1975) Mechanical devices for arterial occlusion. Am J Roentgenol 124:428–430

    Article  CAS  Google Scholar 

  20. Zanetti PH (1987) Cyanoacrylate/iophenylate mixtures: modification and in vitro evaluation as embolic agents. J Interv Radiol 2:65–68

    Google Scholar 

  21. Grady RM, Sharkey AM, Bridges ND (1994) Transcatheter coil embolisation of a pulmonary arteriovenous malformation in a neonate. Br Heart J 71:370–371

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. Gupta P, Mordin C, Curtis J et al (2002) Pulmonary arteriovenous malformations: effect of embolization on right-to-left shunt, hypoxemia, and exercise tolerance in 66 patients. AJR Am J Roentgenol 2:347–355

    Article  Google Scholar 

  23. Yakes WF, Luethke JM, Merland JJ et al (1990) Ethanol embolization of arteriovenous fistulas: a primary form of therapy. J Vasc Interv Radiol 1:89–96

    Article  CAS  PubMed  Google Scholar 

  24. Jackson JE, Mansfield AO, Allison DJ (1996) Treatment of high-flow vascular malformations aided by flow occlusion techniques. Cardiovasc Intervent Radiol 19:323–328

    Article  CAS  PubMed  Google Scholar 

  25. Cho SK, Do YS, Kim DI et al (2008) Peripheral arteriovenous malformations with dominant outflow vein: results of ethanol embolization. Korean J Radiol 9:258–267

    Article  PubMed Central  PubMed  Google Scholar 

  26. Yakes WF, Pevsner P, Reed M et al (1986) Serial embolizations of an extremity AVM with alcohol via direct puncture. AJR Am J Roentqenol 146:1038–1044

    Article  CAS  Google Scholar 

  27. Yakes WF, Haas DK, Parker SH et al (1989) Symptomatic vascular malformations: ethanol embolotherapy. Radiology 170:1059–1066

    Article  CAS  PubMed  Google Scholar 

  28. Takebayashi S, Hosaka M, Ishizuka E (1988) AVMs of the kidney: ablation with alcohol. AJR Am J Roentqenol 150:587–590

    Article  CAS  Google Scholar 

  29. Vinson AM, Rohrer DG, Willcox CW et al (1988) Absolute ethanol embolization for peripheral AVM: report of 2 cures. South Med J 1:1052–1055

    Article  Google Scholar 

  30. Yakes WF, Rossi P, Odink H (1996) How I do it: AVM management. Cardiovasc Intervent Radiol 19:65–71

    Article  CAS  PubMed  Google Scholar 

  31. Yakes WF (1999) Sclerotherapy of craniofacial venous malformations: complications and results. Plast Reconstr Surg 104:12–15

    Article  Google Scholar 

  32. Yakes WF (2004) Endovascular management of high-flow AVMs. Semin Intervent Radiol 21:49–58

    Article  PubMed Central  PubMed  Google Scholar 

  33. Do YS, Park KB, Park HS et al (2005) Ethanol embolization of arteriovenous malformations: interim results. Radiology 235:674–682

    Article  PubMed  Google Scholar 

  34. Vogelzang RL, Atassi R, Vouche M et al (2014) Ethanol embolotherapy of vascular malformations: clinical outcomes at a single center. J Vasc Interv Radiol 25:206–213

    Article  PubMed  Google Scholar 

  35. Ellman BA, Parkhill BJ, Marcus PB (1984) Renal ablation with absolute ethanol: mechanism of action. Invest Radiol 19:416–423

    Article  CAS  PubMed  Google Scholar 

  36. Shin BS, Do YS, Cho HS et al (2010) Effects of repeat bolus ethanol injections on cardiopulmonary he modynamic changes during embolotherapy of arterio-venous malformations of the extremities. J Vasc Interv Radiol 21:81–89

    Article  PubMed  Google Scholar 

  37. Ko JS, Kim JA, Do YS et al (2009) Prediction of the effect of injected ethanol on pulmonary arterial pressure during sclerotherapy of arterio-venous malformations: relationship with dose of ethanol. J Vasc Interv Radiol 20:39–45

    Article  PubMed  Google Scholar 

  38. Do YS, Yakes WF, Shin SW et al (2005) Ethanol embolization of arteriovenous malformations: interim results. Radiology 235:674–682

    Article  PubMed  Google Scholar 

  39. Shin BS, Do YS, Lee BB et al (2005) Multistage ethanol sclerotherapy of soft-tissue aretrio- venous malformations: effect on pulmonary arterial pressure. Radiology 235:1072–1077

    Article  PubMed  Google Scholar 

  40. Lee BB, Do YS, Byun HS et al (2003) Advanced management of venous malformation with ethanol sclerotherapy: mid-term results. J Vasc Surg 37:533–538

    Article  CAS  PubMed  Google Scholar 

  41. Lee BB, Kim DI, Huh S et al (2001) New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation. J Vasc Surg 33:764–772

    Article  CAS  PubMed  Google Scholar 

Download references

Compliance with ethical guidelines

Conflict of interest. W. Yakes and I. Baumgartner state that there are no conflicts of interest. The accompanying manuscript does not include studies on humans or animals.

Author information

Authors and Affiliations

  1. Swedish Vascular Malformation Center, 501 E. Hampden Avenue, Suite 4600, 80113, Englewood, CO, USA

    W. Yakes

  2. Division of Angiology, Swiss Cardiovascular Center, INSELSPITAL, University Hospital, 3000, Bern, Switzerland

    I. Baumgartner

Authors
  1. W. Yakes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. I. Baumgartner
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to W. Yakes or I. Baumgartner.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yakes, W., Baumgartner, I. Interventional treatment of arterio-venous malformations. Gefässchirurgie 19, 325–330 (2014). https://doi.org/10.1007/s00772-013-1303-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00772-013-1303-9

Keywords

Schlüsselwörter

Search

Navigation