Coil embolization of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVMs) are uncommon lesions that can be treated by surgery or interventional radiology. Forty-four PAVMs in 11 patients were occluded by transcatheter coil embolization with only one symptomatic complication, deep venous thrombosis, attributable to the procedure. There was a significant improvement in symptoms and a reduction in pulmonary AV shunting in the 9 patients in whom embolization of all visible discrete lesions was successfully completed. Coil embolization is an effective alternative to other methods of treating PAVMs.     

无水乙醇栓塞治疗先天性肾动静脉畸形

目的 探讨经微导管无水乙醇动脉栓塞治疗先天性肾动静脉畸形的疗效和安全性.方法 回顾性分析11例以肉眼血尿为主要症状的先天性肾动静脉畸形,选择性肾动脉造影确诊为肾动静脉畸形后,超选择性病变动脉插管,用无水乙醇栓塞病变血管治疗.结果 11例患者共进行12次治疗,无水乙醇用量5～25 ml,11例肾动静脉畸形均成功栓塞,栓塞24～48 h内肉眼血尿消失.术后1周内出现栓塞侧腰部酸痛、低热、腹胀、恶心、呕吐等症状,无其他严重并发症.随访4～96个月无血尿复发,肾功能正常.结论 经导管无水乙醇动脉栓寨安全有效、费用低廉,是先天性肾动静脉畸形治疗的有效方法.     

Revascularization of brain arteriovenous malformations after embolization with brucrylate

Summary Between 1984 and 1988, 52 brain arteriovenous malformations (AVMs) were embolized in the Radiology Department of the Toronto Western Hospital. 9 were localized in the occipital lobe. There was angiographic follow-up ranging from one to four years. Two embolized AVMs, both occipital, showed revascularisation at 6 months and two years respectively. In one case the embolization had resulted in a complete obliteration of the AVM. In the other, the nidus was reduced by 95%. It is suggested that the occipital lobe, because of its rich vascularity, is more prone than other parts of the brain to produce intense collateralization leading indirectly to resupply of embolized AVMs. Existence of these collaterals may also explain the rarity of visual defects in occipital AVMs. These cases confirm the need for post therapeutic angiographic controls to assess the stability of the results obtained.     

Reperfusion of pulmonary arteriovenous malformations after embolotherapy

PURPOSE: To describe the mechanisms and risk factors associated with reperfusion of successfully treated pulmonary arteriovenous malformations (PAVMs) after embolotherapy. MATERIALS AND METHODS: Among 112 consecutive patients with PAVMs treated by embolotherapy, 19 patients were identified who had 33 angiographically confirmed reperfused PAVMs. A retrospective analysis of computed tomography (CT) and angiography was performed in patients with documented reperfused PAVMs in which reperfused PAVMs were compared with nonreperfused PAVMs. CT images were examined for persistence of the aneurysm and/or draining vein after initial embolotherapy and correlated with angiography to determine the mechanism of reperfusion. PAVM and embolic agent characteristics (eg, feeding artery size and number; PAVM location; coil size, number, and location) were evaluated for association with reperfusion. The outcomes of repeat embolotherapy for reperfused PAVMs were evaluated. RESULTS: The PAVM aneurysm and/or draining vein persisted on CT after initial embolotherapy in all reperfused PAVMs and resolved in all nonreperfused PAVMs (in patients with nondiffuse PAVMs). Recanalization was the mechanism of reperfusion in 88%. Reperfusion was associated with the use of a single coil (P < .0001), oversized coils (P < .0001), coil placement more than 1 cm from the aneurysm (P < .0001), and increased feeding artery size (P < .001). Repeat embolotherapy for reperfused PAVMs was technically successful in 94% of cases. In the remaining 6% of cases, insufficient feeding artery length prevented safe repeat treatment. After a mean follow-up of 41 months, 42% of reperfused PAVMs in our series have been successfully treated again and occluded. CONCLUSIONS: Recanalization is the most common mechanism of PAVM reperfusion. Increased feeding artery diameter, low number of coils, use of oversized coils, and proximal coil placement within the feeding artery are associated with reperfusion. Distal coil placement facilitates repeat embolization if reperfusion occurs.     

Transcatheter embolization of uterine arteriovenous malformations

A case of congenital arteriovenous malformation of the uterus in a 25-year-old woman with a long-standing history of recurrent menometrorrhagia is reported. Radiological diagnosis was based on hysterographic, computed tomographic, and angiographic findings. Treatment was performed with percutaneous transcatheter embolization.     

无水乙醇栓塞治疗耳部动静脉畸形

目的 介绍22例耳部动静脉畸形无水乙醇介入栓塞治疗的经验.方法 对22例耳部动静脉畸形患者,通过局部穿刺或经导管内超选择径路达到耳部病变的异常血管团内,根据病变的血管团构筑,采用无水乙醇或稀释乙醇进行栓塞,间隔1个月进行电话随访,间隔3～4个月进行临床随访,根据临床检查或血管造影评价临床效果.结果 22例患者共进行了38次无水乙醇栓塞,每次无水乙醇的用量为4～65 ml.9例病变局限患者,1～2次栓塞后达到临床治愈;13例病变广泛患者,无水乙醇栓塞3～5次后,溃疡愈合,出血停止,耳呜消失或减弱.血管造影见9例异常血管团完全消失;8例血管团消失50%～75%;5例血管闭消失小于50%.最常见的并发症为可逆性局部坏死和水疱形成.结论 无水乙醇栓塞是耳部动静脉畸形安全、有效的治疗方式,并有可能成为首选的治疗方式.     

Symptomatic pulmonary complications from liquid acrylate embolization of brain arteriovenous malformations.

PURPOSETo describe symptomatic pulmonary emboli from brain arteriovenous malformation embolization with liquid acrylates and to analyze the reasons for these complications and describe preventive techniques.METHODSThe clinical records of 182 patients embolized with acrylate glue since 1978 for treatment of brain AVMs were searched for evidence of symptomatic pulmonary complications. Originally iso-butyl-2-cyanoacrylate and more recently n-butyl-2-cyanoacrylate were used in all patients. Arteriovenous malformation morphology, amounts and techniques of glue injection, and clinical and radiologic investigations in the symptomatic patients were recorded.RESULTSThree patients had pulmonary symptoms within 48 hours of glue injection. One patient with a left frontal arteriovenous malformation had embolization with an isobutyl-2-cyanoacrylate/pantopaque/acetic acid mixture; severe pleuritic chest pain developed 2 days later. One patient with a left temporal and one with a left cerebellar arteriovenous malformation had embolization with n-butyl-2-cyanoacrylate/lipiodol mixtures; a cough, pleuritic chest pain, and bloody sputum developed in both within 24 hours. Two patients experienced a significant drop in PO2. No flow-arrest techniques were used for any of the injections in these three patients. All patients demonstrated significant changes on chest x-ray and CT chest examinations. All were treated conservatively and recovered spontaneously.CONCLUSIONSSymptomatic pulmonary complications can occur after acrylate glue injection, particularly when delivery systems without flow arrest are used in high-flow vascular brain lesions. Techniques using acetic acid to delay polymerization time and "sandwich" techniques in which glue is pushed with dextrose are also more susceptible to this complication.     

动静脉畸形的无水乙醇栓塞

无水乙醇栓塞治疗动静脉畸形(AVM)已初步取得了令人满意的临床效果并展现出良好的应用前景,从而为彻底治愈AVM提供了一条崭新的途径.但是,无水乙醇栓塞治疗AVM是一项极具挑战性的工作,不恰当应用会引起一系列并发症并可导致严重后果.本文拟对无水乙醇栓塞治疗AVM的机制、技术要点、栓寒治疗后的病理生理变化以及栓塞的并发症及其防治作一叙述.     

螺旋弹簧圈堵塞术治疗先天性肺动静脉瘘

目的总结螺旋弹簧圈(Coil)堵塞术治疗先天性肺动静脉瘘的经验及疗效。方法回顾性分析用Coil弹簧栓堵塞治疗的肺动静脉瘘7例患者,其中单发囊状型4例,多发囊状型2例,多发弥漫型1例。结果7例患者均栓塞成功。6例囊性肺动静脉瘘平均股动脉血氧饱和度由术前87％上升为术后96％。1例弥漫型肺动静脉瘘在栓塞术中出现一过性胸前区隐痛,经分期堵塞血氧饱和度由术前79％上升为87％。随访6个月至5年,仅弥漫型肺动静脉瘘1例血氧饱和度较术后轻度下降,并超声心动图提示出现轻中度右房室瓣关闭不全,余病例均无复发。结论Coil堵塞术治疗先天性囊状型肺动静脉瘘是安全有效的治疗方法,但对弥漫型者仅为一姑息治疗,疗效有待经验总结。     

脑动静脉畸形的血管内栓塞治疗

目的 探讨脑动静脉畸形（ＡＶＭ）血管仙介入治疗的方法和效果。方法 分析８２例ＡＶＭ,其中表现癫痫２０例,颅脑出血５１例,头痛１８例。病灶位于大脑半球６６例,基底节６例,小脑半球７例,脑干３例。畸形血管团属巨大型２３例,中型５０例,小型９例。栓塞剂为ＮＢＣＡ６４例,ＩＢＣＡ１２例,手术丝线４例,手术丝结＋ＩＢＣＡ２例。结果 完全解剖治愈２７例;畸形血管团减少８０％以上１５例;减少５０％～８０％者２８     

Particulate intraarterial embolization in pelvic arteriovenous malformations

Pelvic arteriovenous malformation is a rare disease with a protracted course which is a major therapeutic problem as it is usually not cured by any means. Symptoms are incapacitating and at times life-threatening. Intraarterial embolization can provide symptomatic relief but recurrence of the lesion occurs in most cases. Intraarterial embolization can be repeated several times but becomes increasingly difficult as new collaterals develop while the major feeders remain occluded. Surgical excision is contraindicated except in well localized lesions. In these cases, preoperative embolization may decrease operative morbidity and facilitate a thorough extirpation.     

Clinical and anatomic outcomes after embolotherapy of pulmonary arteriovenous malformations

PURPOSE: To assess long-term clinical and imaging results of technically successful pulmonary arteriovenous malformation (AVM) embolization. MATERIALS AND METHODS: One hundred fifty-five patients with pulmonary AVMs underwent embolization during a period of 3 years. Recommended follow-up included clinical assessment, helical computed tomography, and physiologic evaluation within 1 year and then every 5 years. RESULTS: Hereditary hemorrhagic telangiectasia was present in 148 patients (95%). Four hundred fifteen pulmonary AVMs were occluded during 205 procedures. Clinical follow-up was available in all patients over 3-7 years and imaging follow-up was available in 144 patients (393 lesions) over 1-7 years (mean, 2.9 y). Problems related to pulmonary AVMs occurred in 35 patients (23%) at 42 time points: 22 patients with 23 symptomatic events and 17 patients with 19 asymptomatic events. Symptoms resulted from growth of nonembolized pulmonary AVMs (n = 19), residual embolized pulmonary AVMs (n = 5), or both (n = 2). Symptoms consisted of respiratory manifestations (n = 13), cerebral ischemia (n = 4), brain abscess (n = 5), hemoptysis (n = 3), and seizure (n = 1). Imaging showed pulmonary AVM involution in 97% of embolized lesions and 11 residual lesions (2.8%) in 10 patients (6.9%). These were caused by recanalization (n = 7), presence of an accessory feeding artery (n = 1), pulmonary collateral vessels (n = 1), and bronchial collateral vessels (n = 2). CT detected 10 of the 11 residual lesions. Imaging detected 97 previously small pulmonary AVMs that had enlarged to a significant size in 28 patients (18%), 15 of whom were symptomatic and 13 of whom were asymptomatic. CONCLUSIONS: Clinical and anatomic evaluation after pulmonary AVM embolization is important to detect persistent or reperfused lesions and enlarging lesions, with the latter more common. Patients with persistent, reperfused, or enlarging lesions often have symptoms, but a significant minority of patients are asymptomatic. More frequent assessment may improve detection before the onset of symptoms.     

脑动静脉畸形的DSA血管构筑学及其栓塞治疗

目的：探讨脑动静脉畸形（AVM）的血管构筑特征及血管内栓塞治疗的疗效。方法：采用Seldinger技术及微导管技术超选择性脑执AVM供血动脉造影及血管内栓塞。结果：脑AVM血管结构上分为终末型供血方式,穿支型供血方式及混合式。可伴有动脉瘤或静脉结构异常。本组栓塞治疗技术成功率97.5%,AVM完全消失,解剖治愈11例,AVM畸形血管团大部分消失,其减少大于80%4例,减少50%～80例,小于50%9例。随访6个月至5年,效果满意。结论：超选择性造影可正确指导栓塞治疗。血管内栓塞治疗脑AVM是一种安全、可靠、有效方法。     

NBCA血管内栓塞治疗颅内动静脉畸形

目的　观察α 氰基丙烯酸正丁酯 (NBCA)血管内栓塞治疗脑动静脉畸形 (AVM )的疗效。方法　经股动脉插管 ,用微导管技术超选择病灶内注入NBCA栓塞治疗脑AVM ,共 118例。位于大脑半球 116例 ,小脑半球 2例。病变大于 6cm者 5 2例 ,3～ 6cm者 5 9例 ,小于 3cm者 7例。单支供血动脉13例 ,2支 37例 ,3支以上 6 8例。栓塞加手术切除巨大型脑AVM 15例。结果　完全栓塞病变 2 1例 ,栓塞 90 %以上 5 7例 ,70 %～ 90 % 2 7例 ,5 0 %～ 70 % 8例 ,栓塞 <5 0 %者 5例。结论　NBCA为永久性栓塞剂 ,应作为栓塞治疗颅内AVM的首选材料。栓塞加手术切除、栓塞加伽玛刀或X线刀是彻底治愈脑AVM的较有效手段     

Ethanol embolization of arteriovenous malformations: interim results

PURPOSE: To assess retrospectively the interim results and the complications of ethanol embolization treatment of arteriovenous malformations (AVMs). MATERIALS AND METHODS: Institutional review board approval was obtained for a retrospective review of patient medical and imaging records. Informed consent was not required by the institutional review board. Written consent for the procedure was obtained from all patients after a discussion about the advantages and risks of the procedure. After a general anesthetic was administered, 40 patients (16 male, 24 female; age range, 9-53 years) with inoperable AVMs in the body and extremities underwent staged ethanol embolizations (range, 1-24; median, 3). Pulmonary artery pressure and arterial blood pressure were monitored as ethanol was injected. Ethanol embolizations (50%-100% ethanol mixed with nonionic contrast material) were performed by using transcatheter and/or direct puncture techniques. Ten patients underwent additional coil deployment during ethanol embolization. Clinical follow-up (range, 2-48 months; mean, 14.6 months; median, 12 months) was performed in all patients, and results from imaging follow-up (range, 0-48 months; mean, 8.4 months; median, 6 months) were available from the last treatment session in 28 patients. Therapeutic outcomes were established by evaluating the clinical outcome of symptoms and signs, as well as the degree of devascularization at follow-up angiography. RESULTS: One hundred seventy-five ethanol embolizations were performed in 40 patients. Sixteen (40%) of 40 patients were cured, 11 (28%) had partial remission, seven (18%) had no remission, and one (2%) experienced aggravation. Treatment failed in five patients (12%). Ethanol embolization was considered effective (cure, 16 patients; partial remission, 11 patients) in 27 patients (68%). Eleven patients will need further treatment sessions for residual AVMs. Twenty-one patients (52%) experienced complications. Twenty-seven minor complications (skin and transient peripheral nerve injuries) (27 [15%] of 175 procedures) occurred in 18 (45%) of 40 patients. All minor complications were healed with wound dressing and observation. Five major complications (five [3%] of 175 procedures) occurred in five (12%) of 40 patients, and four patients recovered completely. CONCLUSION: Ethanol embolization has the potential for cure in the management of AVMs of the body and extremities but with acceptable risk of minor and major complications.     

肺动静脉畸形的CT表现

肺动静脉畸形(Pulmonary Arteriovenous Malformation,PAVM)在临床上较为罕见,因其可能引起严重的临床症状诸如脑梗死、致命性大咯血等[1],故及时准确地诊断就显得极为重要.PAVM的CT诊断鲜有文献报道,笔者搜集经肺动脉造影证实的3例PAVM患者,分析其CT表现并复习相关文献,旨在提高PAVM的CT诊断水平.     

Interventional treatment of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVM) are congenital vascular communications in the lungs. They act as right to left shunts so that the blood running through these malformations is not oxygenated or filtered. These patients are typically hypoxaemic with exercise intolerance and are at high risk of paradoxical emboli to the brain and other organs. These malformations are most commonly seen in hereditary haemorrhagic telangiectasia (HHT) (Mb. Osler-Weber-Rendu syndrome). Nowadays, the generally accepted treatment strategy of first choice is embolization of the afferent arteries to the arteriovenous malformations. It is a minimally invasive procedure and at the same time a lung preserving treatment with a very high technical success, high effectiveness and low morbidity and mortality. Embolization prevents cerebral stroke and abscess as well as pulmonary haemorrhage and further raises the functional level. Embolization is a well-established method of treating PAVM, with a significant effect on oxygenation of the blood. Screening for PAVM in patients at risk is recommended, especially in patients with HHT.