Reperfusion of Complex Pulmonary Arteriovenous Malformations After Embolization: Report of Three Cases

The purpose of this report is to discuss the different mechanisms of reperfusion of pulmonary arteriovenous malformations (PAVMs) after embolization. Transcatheter embolotherapy is currently the first-line treatment of PAVMs to prevent neurologic complications or pulmonary hemorrhage. Initial good results can be expected but we report three cases of reperfusion of complex large PAVMs after coil embolization. After adequate embolization, reperfusion of PAVMs may occur by several mechanisms including recanalization of embolized arteries, recruitment of normal arterial branches, growth or enlargment and development of a systemic arterial supply.     

A Modified Metallic Coil Embolization Technique for Pulmonary Arteriovenous Malformations Using Coil Anchors and Occlusion Balloon Catheters

Purpose To evaluate the feasibility and efficacy of a modified metallic coil embolization technique for pulmonary arteriovenous malformations (PAVMs) using coil anchors and occlusion balloon catheters. Methods Five consecutive female patients with 6 PAVMs were included in the present study. One of the 6 PAVMs was of the complex type with four feeding arteries. An occlusion balloon catheter was inserted into the feeding artery as close to the venous sac as possible. The coil anchor, which was a simple W-shaped bent stainless steel wire with two markers at each end, was deployed prior to embolization to prevent the systemic migration of embolic materials. Then, metallic coils were deployed around the coil anchors under inflow stoppage using the inflated occlusion balloon catheter. In the complex-type PAVM, the main feeder was occluded by this technique and the other three small feeders were embolized with metallic coils only. Results In all 5 cases, occlusion balloon catheters could be inserted into the feeding arteries just proximal to the venous sacs, coil anchors were easily deployed, and complete occlusion was achieved without any migration of metallic coils or paradoxical embolism during the procedure. Conclusions The modified metallic coil embolization technique with coil anchors and occlusion balloon catheters was feasible and considered to be useful in preventing procedure-related complications.     

Pulmonary Arteriovenous Malformation and Its Vascular Mimickers

Pulmonary arteriovenous malformation (AVM) is a congenital vascular disease in which interventional radiologists can play both diagnostic and therapeutic roles in patient management. The diagnosis of pulmonary AVM is simple and can usually be made based on CT images. Endovascular treatment, that is, selective embolization of the pulmonary artery feeding the nidus of the pulmonary AVM, and/or selectively either the nidus or draining vein, has become a first-line treatment with advances in interventional devices. However, some vascular diseases can simulate pulmonary AVMs on CT and pulmonary angiography. This subset can confuse interventional radiologists and referring physicians. Vascular mimickers of pulmonary AVM have not been widely known and described in detail in the literature, although some of these require surgical correction, while others require regular follow-up. This article reviews the clinical and radiologic features of pulmonary AVMs and their mimickers.     

Occlusion of pulmonary arteriovenous malformations by use of vascular plug

Pulmonary arteriovenous malformations are commonly treated by embolization with coils or balloons to prevent cerebral complications and to raise the oxygenation of the blood. The Amplatzer vascular plug is a new occlusive device made of a self-expanding cylindrical nitinol mesh. It is fast and safe to position, and can be repositioned before final delivery. It is especially suited for embolization of large high-flow vessels as in pulmonary arteriovenous malformations with big feeding arteries. Two cases of successful use of the new device for treatment of large pulmonary arteriovenous malformations are described.     

经导管血管内栓塞术治疗肺动静脉畸形

目的 评价经皮穿刺经导管栓塞术治疗肺动静脉畸形(PAVMs)的安全性和疗效。资料与方法 对10例PAVMs患者进行了经导管栓塞治疗,男4例,女6例,平均年龄12岁(6个月～28岁),均为先天性。临床表现有紫绀和杵状指／趾7例,劳力性呼吸困难6例,胸部血管杂音4例,咯血2例和心功能不全2例。栓塞时用微型钢丝圈2例,普通钢丝圈8例。结果 PAVMs病灶为多发性7例,单发性3例。10例共做栓塞治疗12次,技术成功率为100％,治疗结束时复查肺动脉造影显示单发病灶完全消失,多发病灶者主要异常血管不再显影。术后血氧饱和度从平均78％增至96％。2例术前存在心功能不全,术后症状消失;胸部血管杂音消失。术后出现轻微胸痛5例,少量胸腔积液3例;1例术后2个月死于栓塞肺叶肺梗死继发化脓性感染。9例随访18个月～9年,一般情况良好,日常生活正常,无神经系统症状和体征,除2例弥漫型动静脉畸形血氧饱和度持续在85％～90％外,其余缺氧症状未再复发。结论 经导管血管内栓塞术是治疗PAVMs的安全、有效方法。     

肺动静脉畸形的综合影像评价

目的 评价各种影像学检查手段诊断肺动静脉畸形的作用。材料与方法 回顾性分析11例肺动静脉畸形患者的各种影像学检查的表现、胸片、肺动静脉造影11例,CT平扫7例（增强4例）,MR扫描2例（PA、MRA）,并计算各种检查方法的敏感性。结果 肺动静脉造影发现病灶29个,病灶呈瘤样扩张的血管,有1条供血动脉和数条引流静脉,引流静脉和左房早期显影。胸片表现为肺内局限结节样影且有异常血管与肺门相连,其敏感性为79.3%(23/29）。CT表现为病灶密度均实,边界光整,并有典型的“血管蒂”征,增强扫描示病灶与肺动脉同步强化,多平面重建（MPR）有助于认识其相关血管,检查敏感性为94.4%(17/18）。MR扫描敏感性的80.8%(4/5）,对比增强肺动脉MR成像（CE MRA）可弥补常规序列的不足,有助于显示病变全貌,图像堪与肺动脉造影相比。结论 胸片可作为筛选方法,而肺动脉造影是诊断的“金标准”;CT可以提供与肺动脉造影相同的诊断信息,在某种程度上可取代肺动脉造影;MR特别是动态增强MRA不仅可以在形态上确认病灶,还可用以评价血流动力学改变和评估预后。胸片与CT是最佳的治疗后随访手段。     

ACR Appropriateness Criteria Clinically Suspected Pulmonary Arteriovenous Malformation

Pulmonary arteriovenous malformations are often included in the differential diagnosis of common clinical presentations, including hypoxemia, hemoptysis, brain abscesses, and paradoxical stroke, as well as affecting 30% to 50% of patients with hereditary hemorrhagic telangiectasia (HHT). Various imaging studies are used in the diagnostic and screening settings, which have been reviewed by the ACR Appropriateness Criteria Vascular Imaging Panel. Pulmonary arteriovenous malformation screening in patients with HHT is commonly performed with transthoracic echocardiographic bubble study, followed by CT for positive cases. Although transthoracic echocardiographic bubble studies and radionuclide perfusion detect right-to-left shunts, they do not provide all of the information needed for treatment planning and may remain positive after embolization. Pulmonary angiography is appropriate for preintervention planning but not as an initial test. MR angiography has a potential role in younger patients with HHT who may require lifelong surveillance, despite lower spatial resolution compared with CT.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.     

经导管血管内栓塞术治疗肢体动静脉畸形（附6例分析）

目的:评价先天性肢体动静脉畸形血管内栓塞治疗的有效性和安全性.材料和方法:6例临床诊断为肢体动静脉畸形的患者,常规行患肢动脉DSA检查,对动静脉瘘(AVF)和畸形血管团分别超选择动脉内栓塞治疗,AVF选用弹簧圈,畸形血管团用无水酒精或平阳霉素碘化油乳剂栓塞.结果:超选择动脉栓塞技术均成功,6例患者栓塞后血管异常杂音及临床症状消除.随访6～13个月6例患者均无严重并发症发生.结论:动脉DSA检查是诊断先天性肢体动静脉畸形最有效方法,而血管内栓塞术是安全有效的微创治疗方法.     

Renal Arteriovenous Fistula with Rapid Blood Flow Successfully Treated by Transcatheter Arterial Embolization: Application of Interlocking Detachable Coil as Coil Anchor

A 70-year-old woman presented to our outpatient clinic with a large idiopathic renal arteriovenous fistula (AVF). Transcatheter arterial embolization (TAE) using interlocking detachable coils (IDC) as an anchor was planned. However, because of markedly rapid blood flow and excessive coil flexibility, detaching an IDC carried a high risk of migration. Therefore, we first coiled multiple loops of a microcatheter and then loaded it with an IDC. In this way, the coil was well fitted to the arterial wall and could be detached by withdrawing the microcatheter during balloon occlusion (pre-framing technique). Complete occlusion of the afferent artery was achieved by additional coiling and absolute ethanol. This technique contributed to a safe embolization of a high-flow AVF, avoiding migration of the IDC.     

Peripheral arteriovenous malformations with a dominant outflow vein: results of ethanol embolization.

OBJECTIVE: To assess retrospectively the treatment results of ethanol embolization of peripheral arteriovenous malformations (AVMs) with a dominant outflow vein (DOV). MATERIALS AND METHODS: Nineteen patients who had peripheral AVMs with a DOV were enrolled in this study (mean age, 29.7 years; range, 15-42 years). Fifty-one ethanol embolizations (mean, 2.7; range, 1-8) were performed by direct puncture (n = 29), the transarterial approach (n = 13), the transvenous approach (n = 5), or a combination of methods (n = 4) under general anesthesia. Coil and/or core-removed guide wire embolization of the DOV or another flow occlusion technique (i.e., use of an external pneumatic pressure cuff) to achieve vascular stasis were required in all patients during ethanol embolization. Clinical follow-up (mean, 22.2 months; range, 1-53 months) was performed for all patients, and imaging follow-up (mean, 22.1 months; range, 2-53 months) from the last treatment session was performed for 14 patients. The therapeutic outcome (cure, improvement, no change, or aggravation) was assessed according to the clinical response and the degree of devascularization at angiography. RESULTS: Ethanol embolization was considered as an effective procedure in all patients. Thirteen (68%) of 19 patients were cured and six displayed improvement. Three of six patients with improvement needed further treatment sessions for residual AVMs. Four patients (21%) experienced a total of eight complications. Five complications (three events of a distal embolism and one event each of a urinary bladder necrosis and a brain infarct related to the accidental cannulation of the common carotid artery during insertion of the Swan-Ganz catheter) were major and three complications (skin necrosis) were minor. CONCLUSION: Peripheral AVMs with a DOV can be effectively treated with a high cure rate by the use of ethanol embolization alone or in conjunction with the use of coil and/or core-removed guide wire embolization.     

Diagnosis and Nonsurgical Management of Uterine Arteriovenous Malformation

Uterine arteriovenous malformation (AVM) is an uncommon problem and traditional treatment by hysterectomy excludes the possibility of future pregnancy. Developments in interventional techniques make transcatheter embolization of the feeding vessel(s) a therapeutic alternative, potentially preserving the patient’s fertility. We present a case of successful endovascular treatment of uterine AVM.     

脊髓血管畸形的血管内栓塞治疗：附九例报告

作者报道了９例经数字减影血管造影（ＤＳＡ）确诊后同时进行血管内栓塞治疗的脊髓血管畸形（ＡＶＭ）病例。根据ＤＳＡ显示的异常血管的部位、形态、分布和供血动脉及引流静脉情况将其分为两型：硬膜动静脉瘘（ＡＶＦ）型和硬膜内ＡＶＭ型，然后经导管注入栓塞物质进行栓塞治疗。栓塞后造影显示ＡＶＭ大部或完全消失，６例栓塞程度达１００％，平均９２．２％。在２个月至３年的随访期内，７例肢体肌力增加，症状明显改善。栓塞后反     

Clinical and Radiological Long-Term Follow-up After Embolization of Pulmonary Arteriovenous Malformations

The purpose was to evaluate the clinical and radiological long-term results of embolization of pulmonary arteriovenous malformations (PAVMs) and to assess the quality of life after treatment. A clinical follow-up was undertaken after 67 months (mean) in 35 consecutive patients with 106 PAVMs. Outcome parameters at follow-up were PaO₂ and patients’ satisfaction. During follow-up, the patients had a clinical examination, measurement of arterial blood gases, chest X-ray, and contrast echocardiography performed and were asked to fill in a questionnaire exploring experience of the treatment and subjective effect of treatment on physical and social functioning. A significant rise in oxygenation of the blood after embolization was measured. In 77% of the patients symptoms improved, and 71% felt better performance. In eight patients, one of the PAVMs was found insufficiently embolized or recanalized at follow-up angiography and therefore were re-embolized. Endovascular embolization for PAVMs is effective. Clinical parameters and quality of life improved significantly. Regular clinical controls after therapy are necessary to discover insufficiently embolized, recanalized or new PAVMs.     

Long-Term Follow-up After Embolization of Pulmonary Arteriovenous Malformations with Detachable Silicone Balloons

Long-term follow-up results after embolization of 13 pulmonary arteriovenous malformations in 10 patients by use of 14 detachable silicone balloons are given. Patients were followed for a mean of 99 months (range, 63–123 months) with chest x-rays and for a mean of 62 months (range, 3–101 months) with pulmonary angiography. Fifty-four percent of the balloons were deflated at latest radiographic chest film follow-up, but at pulmonary angiographic follow-up all embolized malformations were without flow irrespective of whether or not the balloons were visible. Detachable silicone balloons are not available anymore, but use of these balloons for embolization of pulmonary arteriovenous malformations has been shown to be a safe and precise method, with immediate occlusion of the feeding artery and with long-lasting occlusion, even though many balloons deflate with time, leaving a fibrotic scar replacing the pulmonary arteriovenous malformation. No case of recanalization has been discovered, and these results seem to justify a reduced number of controls of these balloon-embolized malformations.     

体部动静脉畸形介入栓塞治疗的临床应用

目的　探讨体部简单动静脉畸形和复杂动静脉畸形的栓塞方法。方法　使用金属钢圈、液性组织胶、可脱离球囊分别对1 0例体部动静脉畸形栓塞。简单动静脉畸形采用金属钢圈或可脱离球囊对供血动脉直接栓塞以闭塞畸形的血管。复杂动静脉畸形采用组织胶栓塞异常血管团 ,阻断多支动脉供血或防止侧枝血管建立引起的复发。结果　 1 0例体部动静脉畸形栓塞后畸形血管完全闭塞 ,经 1～ 6年随访无复发。结论　介入栓塞对体部动静脉畸形是一种方法简便、疗效可靠的治疗方法 ,是临床治疗体部动静脉畸形的首选方法     

Giant High-Flow Type Pulmonary Arteriovenous Malformation: Coil Embolization with Flow Control by Balloon Occlusion and an Anchored Detachable Coil

Pulmonary arteriovenous malformations (PAVMs) are often treated by pushable fibered or non-fibered microcoils, using an anchor or scaffold technique or with an Amplatzer plug through a guiding sheath. When performing percutaneous transcatheter microcoil embolization, there is a risk of coil migration, particularly with high-flow type PAVMs. The authors report on a unique treatment in a patient with a giant high-flow PAVM whose nidus had a maximum diameter of 6 cm. A detachable coil, not detached from a delivery wire (an anchored detachable coil), was first placed in the feeding artery under flow control by balloon occlusion, and then multiple microcoils were packed proximally to the anchored detachable coil. After confirming the stability of the microcoils during a gradual deflation of the balloon, we finally released the first detachable coil. The nidus was reduced in size to 15 mm at one year postoperatively.     

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.     

ONYX胶栓塞治疗颅内动静脉畸形的临床应用

目的:探讨应用Onyx胶栓塞治疗颅内动静脉畸形的应用价值。方法:全麻下经股动脉穿刺插管,微导管超选择插管到达病变部位后,用Onyx栓塞治疗颅内动静脉畸形30例。结果:30例颅内动静脉畸形患者,共行47次栓塞治疗,畸形血管团栓塞达80%以上者8例,其中4例完全栓塞,栓塞50%~80%者15例,栓塞50%以下者7例。发生颅内出血并发症2例,球麻痹1例,经过相应处理后好转。结论:Onyx是治疗脑动静脉畸形较为理想的栓塞材料,血管内栓塞是颅内动静脉畸形综合治疗中重要的组成部分。     

肺动静脉瘘的栓塞治疗（附六例报告）

笔者报告了６例肺动静脉瘘的栓塞治疗。经造影证实：弥漫性肺小动静脉瘘３例，多发囊状肺动静脉瘘１例，单发囊状肺动静脉瘘２例。栓塞材料为弹簧钢圈，技术操作成功５例，１例发生逆栓塞，但未产生不良后果。术后动脉血氧饱和度从７８％上升到９０％。缺氧症状及紫绀有明显好转。栓塞术是治疗肺动静脉瘘的有效方法。     

Successful Management with Glue Injection of Arterial Rupture Seen during Embolization of an Arteriovenous Malformation Using a Flow-Directed Catheter: A Case Report

We present a case in which an arterial rupture occurring during embolization of an arteriovenous malformation of the left occipital lobe with a flow-directed microcatheter, was successfully sealed with a small amount of glue. We navigated a 1.8-Fr Magic catheter through the posterior cerebral artery, and during superselective test injection, extravasation was observed at the parieto-occipital branch. The catheter was not removed and the perforation site was successfully sealed with a small amount of glue injected through the same catheter. Prompt recognition and closure of the perforation site is essential for good prognosis.