scholarly journals Techniques of Onyx Embolization of Arteriovenous Malformation: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kathryn M Wagner ◽  
Visish M Srinivasan ◽  
Peter Kan
Keyword(s):  
Informed Consent ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Great Care ◽  
Endovascular Techniques ◽  
Definitive Therapy ◽  
Feeding Vessels ◽  
Multiple Feeding ◽  
Staged Treatment

Abstract Advances in endovascular techniques and tools have allowed for treatment of complex arteriovenous malformations (AVMs), which historically may have posed unacceptable risk for open surgical resection. Endovascular treatment may be employed as an adjunct to surgical resection or as definitive therapy. Improvements in embolization materials have made endovascular AVM treatment safer for patients and useful across a variety of lesions. While many techniques are employed for transarterial AVM embolization, the essential tenets apply to all procedures: (1) great care should be taken to cannulate only vessels directly supplying the lesion, and not en passage vessels, prior to injecting embolisate; (2) embolisate should travel into the nidus, but not into the draining veins; (3) embolistate reflux proximal to the microcatheter should be avoided. There are several techniques that accomplish these goals, including the plug and push method, or using a balloon to prevent embolisate reflux. We use controlled injection of liquid Onyx (Medtronic), with increasing pressure over multiple injections pushing the embolisate forward into the AVM. This is repeated in multiple feeding vessels to decrease or eliminate supply to the AVM. Here, we present a 36-yr-old female with a right parietal AVM discovered on workup of headaches. After informed consent was obtained, she underwent preoperative embolization using this technique prior to uncomplicated surgical resection. The video shows the endovascular Onyx embolization of multiple feeding vessels over staged treatment.

Surgical Management Of Posterior Fossa Arteriovenous Malformations

2006 ◽  
Vol 58 (suppl_4) ◽  
pp. ONS-189-ONS-201 ◽  
Author(s):  
John Sinclair ◽  
Michael E. Kelly ◽  
Gary K. Steinberg
Keyword(s):  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Cranial Nerves ◽  
Venous Drainage ◽  
Cerebellar Nuclei ◽  
Preoperative Embolization ◽  
Frameless Stereotaxy ◽  
Microsurgical Resection

Abstract Objective: Arteriovenous malformations (AVMs) involving the cerebellum and brainstem are relatively rare lesions that most often present clinically as a result of a hemorrhagic episode. Although these AVMs were once thought to have a more aggressive clinical course in comparison with supratentorial AVMs, recent autopsy data suggests that there may be little difference in hemorrhage rates between the two locations. Although current management of these lesions often involves preoperative embolization and stereotactic radiosurgery, surgical resection remains the treatment of choice, conferring immediate protection to the patient from the risk of future hemorrhage. Methods: Most symptomatic AVMs that involve the cerebellum and the pial or ependymal surfaces of the brainstem are candidates for surgical resection. Preoperative angiography and magnetic resonance imaging studies are critical to determine suitability for resection and choice of operative exposure. In addition to considering the location of the nidus, arterial supply, and predominant venous drainage, the surgical approach must also be selected with consideration of the small confines of the posterior fossa and eloquence of the brainstem, cranial nerves, and deep cerebellar nuclei. Results: Since the 1980s, progressive advances in preoperative embolization, frameless stereotaxy, and intraoperative electrophysiologic monitoring have significantly improved the number of posterior fossa AVMs amenable to microsurgical resection with minimal morbidity and mortality. Conclusion: Future improvements in endovascular technology and stereotactic radiosurgery will likely continue to increase the number of posterior fossa AVMs that can safely be removed and further improve the clinical outcomes associated with microsurgical resection.

Curative treatment for low-grade arteriovenous malformations

2019 ◽  
Vol 12 (1) ◽  
pp. 48-54 ◽  
Author(s):  
Arthur Wang ◽  
Grace K Mandigo ◽  
Neil A Feldstein ◽  
Michael B Sisti ◽  
E Sander Connolly ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Curative Treatment ◽  
Embolic Agent ◽  
Preoperative Embolization ◽  
Low Grade ◽  
The Mean

BackgroundSpetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.ObjectiveTo assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.MethodsWith institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.Results258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.ConclusionsCurative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.

Clinical significance of pedicle aneurysms on feeding vessels, especially those located in infratentorial arteriovenous malformations

2000 ◽  
Vol 92 (6) ◽  
pp. 995-1001 ◽  
Author(s):  
Manfred Westphal ◽  
Ulrich Grzyska
Keyword(s):  
Arteriovenous Malformations ◽  
Endovascular Techniques ◽  
Treatment Procedure ◽  
Major Hemorrhage ◽  
Content Type ◽  
Ruptured Aneurysms ◽  
Aggressive Management ◽  
Feeding Vessels ◽  
Fine Print ◽  
Feeding Vessel

Object. The diminishing threshold for the application of neuroimaging leads to an increasingly frequent diagnosis of previously asymptomatic arteriovenous malformations (AVMs). In such a context, it is warranted to define the criteria that make a lesion potentially hazardous so that neurosurgeons and patients reach a decision concerning how to manage the AVM. In addition to the proposed grading system for AVMs, which assesses the risk of an actual treatment procedure, several studies have been concerned with the evaluation of angioarchitectural features. The goal of the present study is to demonstrate the significance of feeding vessel pedicle aneurysms, especially those found in infratentorial AVMs.Methods. To determine the incidence of associated aneurysms, the authors reviewed an unselected cohort of 242 consecutive patients with AVMs managed between 1989 and 1999. Within this group were 240 patients who were treated by surgery, endovascular techniques, or a combination of both. Of these patients, 216 harbored a supratentorial and 24 an infratentorial AVM. Two additional patients with supratentorial AVMs underwent treatment of ruptured aneurysms without treatment of the AVMs. In six of the patients with supratentorial AVMs, proximal flow-related aneurysms were found on major feeding arteries, only one of which had caused hemorrhage. In only one patient were there additional distal feeding vessel pedicle aneurysms near the AVM, one of which had caused a major hemorrhage. In contrast, four of 24 patients with infratentorial AVMs had distal feeding artery pedicle aneurysms. Three of these aneurysms had caused hemorrhage.Conclusions. Pedicle aneurysms on feeding vessels are frequently associated with hemorrhage (four of five cases in this series). In our cohort of 242 treated patients (240 treated for AVM and two for an aneurysm), feeding vessel pedicle aneurysms appear to occur more frequently in conjunction with infratentorial AVMs, which justifies aggressive management to prevent incidences of morbidity associated with rupture of the aneurysm.

Interventional embolization of giant thoracic tumors before surgical resection

2013 ◽  
Vol 54 (1) ◽  
pp. 61-66 ◽  
Author(s):  
Feng-Yong Liu ◽  
Mao-Qiang Wang ◽  
Qing-Sheng Fan ◽  
Feng Duan ◽  
Zhi-Jun Wang ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Blood Loss ◽  
Polyvinyl Alcohol ◽  
Surgical Resection ◽  
Efficient Method ◽  
Preoperative Embolization ◽  
Patient Records ◽  
Operative Field ◽  
Feeding Vessels ◽  
Pva Particles

Background Preoperative embolization of tumors is a well-established procedure that has been successfully applied in various clinical situations. Preoperative embolization can reduce the vascularity of tumors resulting in a clearer operative field, less difficult dissection, decreased blood loss, and, in some cases, a decrease in tumor size. However, few studies have been conducted regarding the preoperative embolization of giant thoracic tumors. Purpose To examine the effectiveness and safety of interventional embolization of giant thoracic tumors before surgical resection. Material and Methods A total of 14 consecutive patients with giant thoracic tumors received angiography and the feeding arteries of the tumors were embolized using polyvinyl alcohol (PVA) particles and gelatin sponges 1 day before surgical resection. The patient records were retrospectively reviewed and data regarding diagnoses, embolization, and surgical resection were recorded. Results Angiography revealed the feeding arteries of the tumors to be characterized by multiple branches and thickened vessel trunks with abnormal distal branches superimposed of the tumor shadow. Embolization was successfully without complications in all patients, and all feeding vessels of each tumor were occluded. Embolization reduced the severity of bleeding during surgery and decreased the difficulty of resection of the tumor. No intraoperative or postoperative complications occurred. Conclusion Interventional embolization is a safe and efficient method to facilitate the surgical resection of giant thoracic tumors.

Recurrence of Cerebral Arteriovenous Malformations Following Resection in Adults

Neurosurgery ◽  
2015 ◽  
Vol 78 (4) ◽  
pp. 562-571 ◽  
Author(s):  
Alexander A. Ivanov ◽  
Ali Alaraj ◽  
Fady T. Charbel ◽  
Victor Aletich ◽  
Sepideh Amin-Hanjani
Keyword(s):  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Pediatric Population ◽  
Statistical Significance ◽  
Adult Population ◽  
Venous Drainage ◽  
Preoperative Embolization ◽  
Eligibility Criteria ◽  
Complete Surgical Resection

Abstract BACKGROUND: Complete surgical resection of arteriovenous malformations (AVMs), documented by postoperative angiography, is generally felt to represent cure, obviating the need for long-term follow-up imaging. Although AVM recurrence has been reported in the pediatric population, this phenomenon has only rarely been documented in adults. Recurrence after treatment solely with embolization, however, has been reported more frequently. Thus, patients undergoing multimodal therapy with surgery following preoperative embolization may also be at higher risk for recurrence. OBJECTIVE: To determine if preoperative embolization contributes to recurrences of AVMs after complete surgical resection. METHODS: A retrospective study of patients undergoing AVM resection was performed. Those with complete surgical AVM resection, confirmed by negative early postoperative cerebral angiography and with available follow-up angiographic imaging –6 months postoperatively were included. RESULTS: Two hundred three patients underwent AVM resection between 1995 and 2012. Seventy-two patients met eligibility criteria. There were 3 recurrences (4%). Deep venous drainage and diffuse type of AVM nidus were significantly associated with recurrence. Although preoperative embolization did not reach statistical significance as an independent risk factor, radiographic data supported its role in every case, with the site of recurrence correlating with deep regions of nidus previously obliterated by embolization. CONCLUSION: AVM recurrences in the adult population may have a multifactorial origin. Although deep venous drainage and diffuse nidus are clearly risk factors, preoperative embolization may also be a contributing factor with the potential for recurrence of unresected but embolized portions of the AVM. Follow-up angiography at 1 to 3 years appears to be warranted.

The effect of embolization with N-butyl cyanoacrylate prior to surgical resection of cerebral arteriovenous malformations

1993 ◽  
Vol 78 (1) ◽  
pp. 60-69 ◽  
Author(s):  
Jafar J. Jafar ◽  
Adam J. Davis ◽  
Alejandro Berenstein ◽  
In Sup Choi ◽  
Mark J. Kupersmith
Keyword(s):  
Blood Loss ◽  
Surgical Resection ◽  
Surgical Complications ◽  
Neurological Outcome ◽  
Arteriovenous Malformations ◽  
Operative Time ◽  
Preoperative Embolization ◽  
Intraoperative Blood Loss ◽  
Cerebral Arteriovenous Malformations ◽  
Significant Difference

✓ Endovascular therapy of cerebral arteriovenous malformations (AVM's) is an accepted adjunct to surgical therapy. However, the literature has not characterized the benefits or the liabilities of preoperative embolization. This series compares two groups of patients who underwent surgical resection of a cerebral AVM; one group (20 patients) received preoperative transfemoral selective embolization with N-butyl cyanoacrylate (NBCA) and the other group (13 patients) did not. In the group with preoperative embolization, the AVM's were larger (3.9 vs. 2.3 cm) and of a higher Spetzler-Martin grade (3.2 vs. 2.5) as compared to the nonembolized group. The NBCA embolization facilitated surgical resection. Arteries supplying the vascular malformation were readily distinguished from those supplying the normal brain parenchyma. Embolized vessels were compressible and easily cut with microscissors. No bleeding occurred from transected vessels. Operative time and intraoperative blood loss for the two groups were not statistically different, despite the significant differences in lesion size and grade. Endovascular complications included immediate and delayed hemorrhage (15%) and transient ischemia (5%); there were no embolization-related deaths. Postoperative complications for both groups included hemorrhage (15%), residual AVM (6%), and cerebrospinal fluid leak (3%); the mortality rate was 3%. There was no statistically significant difference in surgical complications between the embolized and nonembolized groups. Most patients (91%) in both groups had an excellent or good late neurological outcome, with no significant difference between the groups. This study concludes that preoperative NBCA embolization of AVM's makes lesions of larger size and higher grade the surgical equivalent of lesions of smaller size and lower grade by reducing operative time and intraoperative blood loss, with no statistically significant difference in surgical complications or long-term neurological outcome.

Preoperative Balloon Occlusion of Arteriovenous Malformations

Neurosurgery ◽  
1988 ◽  
Vol 22 (2) ◽  
pp. 301-308 ◽  
Author(s):  
V. Van Halbach ◽  
Randall T. Higashida ◽  
Peter Yang ◽  
Stan Barnwell ◽  
Charles B. Wilson ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Vascular Anatomy ◽  
Balloon Occlusion ◽  
Neurological Deficits ◽  
Permanent Occlusion ◽  
Feeding Vessels ◽  
Normal Perfusion Pressure Breakthrough ◽  
Surgical Adjunct ◽  
Risk Of Hemorrhage

Abstract Many materials have been utilized to embolize cerebral arteriovenous malformations (AVMs) preoperatively. Specific vascular anatomy with large feeding vessels deep to the nidus or aneurysms within feeding arteries favor the use of detachable balloons over other embolic agents. Detachable balloons allow test occlusion of a vascular pedicle before permanent occlusion and can obliterate aneurysms in feeding arteries. We describe 36 feeder arterial balloon occlusions performed in 31 patients. Twenty-nine patients subsequently had surgical resection. None of the patients developed normal perfusion pressure breakthrough or required blood transfusions. The preoperative balloon occlusion was judged by the neurosurgeon to decrease significantly the difficulty in surgical resection of the malformation. The remaining 2 patients underwent embolization before radiosurgery. One patient had aneurysms in the feeding artery, which was balloon-occluded to diminish the risk of hemorrhage. There were two neurological deficits and three asymptomatic arterial dissections related to the balloon procedure. Balloon occlusion of feeding arterial pedicles in selected cerebral AVMs may be a valuable surgical adjunct. (Neurosurgery 22:301-308, 1988)

Dual cerebral and meningeal supply to giant arteriovenous malformations of the posterior cerebral hemisphere

1980 ◽  
Vol 52 (2) ◽  
pp. 153-161 ◽  
Author(s):  
Miguel A. Faria ◽  
Alan S. Fleischer
Keyword(s):  
Cerebral Hemisphere ◽  
Arteriovenous Malformations ◽  
Internal Carotid ◽  
External Carotid Artery ◽  
External Carotid ◽  
Preoperative Embolization ◽  
Content Type ◽  
Vertebral Arteries ◽  
Feeding Vessels ◽  
Carotid And Vertebral Arteries

✓ Seven cases of giant posterior hemisphere arteriovenous malformations are described. The significance of meningeal feeding vessels from the external carotid artery in addition to the primary cerebral supply through the internal carotid and vertebral arteries to these malformations is discussed. The necessity of bilateral selective external carotid arteriography is stressed, and the value of preoperative embolization is questioned.

scholarly journals Preoperative Embolization in Tandem with Surgical Resection for Cerebral Arteriovenous Malformations

Cureus ◽  
2018 ◽  
Author(s):  
Richa Thakur ◽  
Ali S Haider ◽  
Ashley Thomas ◽  
Steven Vayalumkal ◽  
Umair Khan ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Cerebral Arteriovenous Malformations

scholarly journals Resection of complex occipital arteriovenous malformation with giant varix: demonstration of microsurgical technique

2017 ◽  
Vol 43 (videosuppl1) ◽  
pp. V5
Author(s):  
Pinar Eser Ocak ◽  
Cem Dinc ◽  
Ulaş Cikla ◽  
Mustafa K. Başkaya
Keyword(s):  
Clinical Outcome ◽  
Arteriovenous Malformation ◽  
Surgical Resection ◽  
Cognitive Deficits ◽  
Arteriovenous Malformations ◽  
Single Stage ◽  
Preoperative Embolization ◽  
Microsurgical Technique ◽  
Link Type ◽  
Improve Patient

The complexity of arteriovenous malformations (AVMs) does not necessarily preclude surgical resection. In this video the authors present a 72-year-old male who was known to have an occipital AVM with a large draining varix for the previous 10 years. The patient had progressively worsening visual and cognitive deficits over several years. Total surgical resection was achieved following single stage preoperative embolization. Although resection of the AVMs is challenging, even in experienced hands, it offers a cure and may improve patient clinical outcome.The video can be found here: https://youtu.be/YI1AwGjJdvo.

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