Endovascular treatment of arterio-venous malformations: how to treat lesions with different angioanatomy? LINC 2019 Leipzig, Germany, 23. January 2019 Walter A. Wohlgemuth University Clinic and Policlinic of Radiology Martin-Luther University Halle-Wittenberg, Germany
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Endovascular treatment of arterio-venous malformations ... · Angiographic classification of AVM Type I Arterio-venous fistula Up to 3 direct fistulas without circumscribed nidus
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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
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
Right-sided pelvic AVM, Type II with DOV, MRA in 2018Massive progress, venous flow-related aneurysm enlargement
Very painful dilated draining veins at perineum
Transvenous retrograde injection: 2 venous drainages Good chance to occlude the outflow
Complete occlusion in one session withvenous outflow occlusion and EVOH
Residual AVM type III b after EVOH embolisation
„Finishing“ with direct-punctureethanol
Ulcerationhealed after 4 months withethanolinjections
Endovascular treatment of peripheral AVM
• According to angio anatomy• Type I (AVF), e. g. pulmonary AVM/AVF in HHT Quite simple (Coils, AVP)
• Type II with dominant venous outflow transvenous + retrograde treatment options Good long-term results when venous outflow occluded EVOH, as adjunct: coils/AVP for flow-modulation
• Type III, diffuse, net-like „Nidus“, multiple venous drainages Direct puncture, i.a., i.v. Difficult to treat EVOH firstline, „finishing“ with ethanolMEK1-Inhibitors, MAP2K1 pathway modulators (?) Sometimes palliative results