endovascular treatment of arterio-venous malformations ... · angiographic classification of avm...
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Endovascular treatment ofarterio-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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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
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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
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Type I
Arterio-venous fistula
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Type I
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DOV
A V
Arteriolo-venous Malformation with DOV
Type II
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Type IIIa
Arteriolo-venulous Malformation(microfistulous with non-dilated drainage)
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Type IIIb
Arteriolo-venulous Malformation(dilated drainage)
A V
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Right-sided pelvic AVM, Type II with DOV, MRA in 2018Massive progress, venous flow-related aneurysm enlargement
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Very painful dilated draining veins at perineum
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Transvenous retrograde injection: 2 venous drainages Good chance to occlude the outflow
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Complete occlusion in one session withvenous outflow occlusion and EVOH
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Residual AVM type III b after EVOH embolisation
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„Finishing“ with direct-punctureethanol
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Ulcerationhealed after 4 months withethanolinjections
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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
• Wrong technique worsens situation (PVA, coils etc.) !
Müller-Wille R, Wildgruber M, Sadick M, Wohlgemuth WA. Vascular Anomalies (Part II): Interventional Therapy of Peripheral Vascular Malformations.Fortschr Röntgenstr 2018; 190:927-937
Wohlgemuth Walter A, Müller-Wille René, Teusch Veronika, Dudeck Oliver, Cahill Anne Marie, Alomari Ahmad, Uller Wibke. The retrograde transvenous push-through method: a novel treatment of peripheral arteriovenous malformations with dominant venous outflow. Cardiovasc Intervent Radiol 2015; 38: 623-631
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Summary
• AVM treatment. angioanatomy decides agent
– Type I (e.g. in HHT): plug, coil
– Type II (with DOV): transvenous occlusion
– Type III (nidus as network): EVOH, finishing withethanol
• Be familiar with all agents
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Univ.-Prof. Dr. Dr. Walter A. Wohlgemuth1) University Clinic and Policlinic of Radiology, Martin-Luther University Halle-Wittenberg, Germany
2) German Interdisciplinary Society of Vascular Anomalies
www.compgefa.de
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Endovascular treatment ofarterio-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