Korean J Radiol.  2008 Jun;9(3):258-267. 10.3348/kjr.2008.9.3.258.

Peripheral Arteriovenous Malformations with a Dominant Outflow Vein: Results of Ethanol Embolization

• Cho SK
• Do YS
• Kim DI
• Kim YW
• Shin SW
• Park KB
• Ko JS
• Lee AR
• Choo SW
• Choo IW

• KMID: 1758460
• DOI: http://doi.org/10.3348/kjr.2008.9.3.258

Abstract

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.

Keyword

Arteriovenous malformations, extremities; Arteriovenous malformations, pelvic; Arteriovenous malformations, therapeutic embolization

MeSH Terms

Adolescent
Adult
Arteriovenous Malformations/*therapy
Embolization, Therapeutic/*methods
Ethanol/*therapeutic use
Female
Follow-Up Studies
Humans
Male
Retrospective Studies
Treatment Outcome

Figure

• 

  Fig. 1 Diagram and angiographic example of peripheral arteriovenous malformations with dominant outflow vein. A. Peripheral arteriovenous malformations with dominant outflow vein have arteriovenous shunts (S) between multiple arterial components (A) and dilated venous component (V) of nidus. Dilated venous component of nidus appears as initial part of large outflow vein on angiography. B, C. Arterial (B) and venous (C) phases of selective posteroanterior angiogram of arteriovenous malformation with dominant outflow vein in left forearm show multiple arterial feeders that shunt into wall of large dilated outflow vein (arrows).

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  Fig. 2 23-year-old woman with pain at left calf (patient 5). A, B. Arterial (A) and venous (B) phases of pretreatment posteroanterior angiogram show multiple feeding arteries (arrowheads) with plexiform appearance and dilated outflow vein (arrows). C. Multiple coils (arrows) were placed into dilated outflow vein through direct puncture approach, and then 19 mL of absolute ethanol was injected through needle. D. Final posteroanterior angiogram shows complete obliteration of arteriovenous malformation. There was no evidence of recurrence at 40-month imaging and clinical follow-up (data not shown).

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  Fig. 3 28-year-old man with painful pulsating mass in left shoulder (patient 8). A, B. Arterial (A) and venous (B) phases of pretreatment posteroanterior angiogram show multiple feeding arteries (arrowheads) and huge dilated outflow vein (arrows). Note coil (open arrow) that was previously placed into feeding artery at another hospital. C. Arterial phase of left anterior oblique angiogram shows complete obliteration of arteriovenous malformations after three sessions of embolization with 40 mL, 55 mL, and 16 mL of absolute ethanol, respectively, by using direct puncture of dilated outflow vein. In every session, multiple core-removed guide wires were placed into outflow vein through direct puncture approach prior to ethanol injection. Total of 87 core-removed guide wires (arrows) were placed into outflow vein. Patient complained of discomfort due to mass effect of guide wires after completion of embolization and two months later, patient underwent surgical removal of arteriovenous malformation containing guide wires without any complications.

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