1. Scott L. Stevens, M.D. & Mark A. Farber, M.D.
Postgraduate Course:
Venous Endovascular
Course Directors:
Scott L. Stevens, M.D. & Mark A. Farber, M.D.

2. Introduction
Kim Hansen, MD
WFU School of Medicine
Winston-Salem, NC

3. Arteriovenous Malformations.
Alan B. Lumsden, Chairman Cardiovascular Surgery
Houston, Texas

4. Vascular Lesion Treatment
Arteriovenous Malformation (AVM)
Definition - Congenital lesion
Abnormal arteriovenous communications
Feeding arteries
Nidus
Outflow veins
Symptoms
Significant shunting / CV compromise
Pain, neuromuscular dysfunction, tissue ulceration
Hemorrhage
An arteriovenous malformation or AVM is a congenital – often deep – lesion. 8
Anatomically, an AVM is comprised of many abnormal communications between adjacent arteries and veins. Feeding arteries lead to this tangled web of dilated vessels – the AVM nidus – while veins provide for outflow. 8
Symptoms of an AVM are dependent upon its size and location. A large AVM produces significant shunting and can lead to cardiovascular compromise. With the local disruption in blood flow, symptoms such as pain, neuromuscular dysfunction or tissue ulceration can occur. AVM rupture results in hemorrhage.

5. Treatment
Absolute indications
Hemorrhage
Ischemia (steal)
Refractory ulceration
Congestive heart failure
Relative indications
Disabling pain
Claudication
Functional impairment

6. Treatment Conservative Stockings Limb elevation Surgery 10% lesions
Best after embolization
100% success when amenable for resection

7. Vascular Lesion Treatment
AVM Embolization
Effective therapy
Destruction of the nidus
Procedural requirements
Superselective access to feeding artery
Injection non-resorbable embolic
agent into the nidus
Therapeutic vascular embolization may provide effective therapy for AVMs. However, unlike other embolization procedures which focus on either proximal or distal arterial embolization… 8
the goal of AVM embolization is destruction of the nidus. Embolization of a feeding artery would merely shift blood supply to an adjacent artery, and the AVM would remain. 8
However, superselective access to the feeding artery and injection of a non-resorbable embolic agent into the nidus may produce durable occlusion. 8
Embolic agents used for AVM embolization include PVA particles and microspheres, coils, absolute ethanol and n-BCA.
Contour PVA particles / Contour-SE microspheres
Absolute ethanol
n-BCA
.014”/.035” Coils (Vortx-18 or Vortx-35)

8. Present understanding phases vascular development.
Embryology
Stage I Undifferentiated: primitive blood lakes, capillary networks, no veins or arteries
Stage II Retiform: Capillaries form large plexiform structures
Stage III Maturation:
Mature vascular channels

10. MRI Classification

11. What do we really need to know?
Location:
subcutaneous
deep to fascia
both
Proximity to major structures
sciatic nerve
rectum
Localized or diffuse
Arterial or venous
relative contribution

12. towel roll

13. head
foot
rectus femoris
femoral nerve branches
tensor fascia lata

14. venous connection

15. joint capsule
femur

17. Treatment Embolization Multiple sessions Long-term commitment
Usually under general anesthesia
Some report 79% success with 20% complications

18. Steps for safe embolization
Good preliminary angiography
Think about collateral pathways
Use shortest straightest approach, especially when coils used
Stable catheter position and verify:
Wire if using coils
Contrast if soluble agent
Use non-heparinized saline to flush and dilute contrast
Continuous fluoro during embolization
Intermittent runs to evaluate flow

19. Vascular Lesion Treatment
AVM Embolization Hazards
Non-Target Distal embolic embolization
Venous outflow vessels pulmonary circulation
Potentially fatal PE (Pulmonary Embolism)
Prevention
Proper sizing of PVA microspheres / particles
Impact within the nidus
Careful injection of liquid embolics
Contain effects within nidus
Proper sizing of coils
Reduce risk of displacement

21. Non-resorbable Embolic Agents: Liquid Embolic Agent
n-Butyl Cyanoacrylate (n-BCA)
Description
Tissue adhesive or “glue”
Treatment of cerebral AVMs
Mechanism of action
Polymerization upon contact with ionic fluids
Formation of a solid cast within the vessel
Vessel occlusion
Technique
Coaxial delivery
Flushing with non-ionic dextrose solution
Immediate catheter withdrawal

22. AVM dorsum left hand
Draining vein punctured
Tourniquet above arterial pressure
2.5cc absolute ETOH via 3Fr catheter

23. Radial Head AVM, multiple vessels feeding venous component.
Catheter inserted into draining vein.
Absolute alcohol injected in 4 stages.
Venogram at 6 months - ablation of veins

24. Early Polymerization n-BCA adherent to tip at risk for embolus
TRUFILL ® n-BCA mixture solidifies:
In the microcatheter - catheter occlusion
In the AVM before the desired depth of penetration within a feeding pedicle
At the microcatheter tip
n-BCA adherent to tip at risk for embolus
n-BCA adherent to tip at risk for catheter retention
Reflux, polymerization of non-target vessel
Complications:
Ischemia
AVM or vessel rupture

25. Conclusion: AVM Treatment
These patients lack a home
Vascular Surgeons see most of AVM,s
No single therapeutic option
Need broad oversight
Emerging advanced endovascular skills in vascular surgery community
Rapid growth of excellent imaging
MEN -1 of vascular surgery: patient for life
Research- clinical- teaching opportunities

26. TRUFILL® Tantalum Powder
Finely ground, irregularly shaped, dark gray metal
Used with TRUFILL ® Ethiodized Oil to radiopacify TRUFILL n-BCA liquid embolic agent
Mix tantalum with TRUFILL ® Ethiodized Oil prior to mixing with TRUFILL ® n-BCA
DO NOT use TRUFILL ® Tantalum Powder alone as a radiopacifying agent for n-BCA

27. TRUFILL® Ethiodized Oil
Straw to amber colored oily fluid
Contains 37% iodine organically combined w/ poppyseed oil’s ethyl esters of fatty acids
Injectable, radiopaque agent to be used with n-BCA Liquid Embolic System to control polymerization
DO NOT use TRUFILL ® Ethiodized Oil alone as a diagnostic agent

28. TRUFILL® n-BCA Procedure Set-up
Inject TRUFILL ® Ethiodized Oil
into sterile beaker

29. TRUFILL® n-BCA Procedure Set-up
Add TRUFILL Tantalum Powder
to sterile beaker

30. TRUFILL® n-BCA Procedure Set-up
Mix TRUFILL Ethiodized Oil
and TRUFILL Tantalum Powder

31. TRUFILL® n-BCA Procedure Set-up
Attach self-piercing cap to the syringe;
then attach to the TRUFILL n-BCA vial

32. TRUFILL® n-BCA Procedure Set-up
Aspirate TRUFILL n-BCA into syringe

33. TRUFILL® n-BCA Procedure Set-up
Add TRUFILL n-BCA to mixture in beaker
and mix thoroughly

34. TRUFILL® n-BCA Procedure Set-up
Rinse microcatheter hub with syringe of D5W

35. TRUFILL® n-BCA Procedure Set-up
Flush microcatheter with D5W

36. TRUFILL® n-BCA Procedure Set-up
Aspirate TRUFILL n-BCA mixture into syringe;
Compare mixture-filled syringe with contrast-filled syringe
under fluoroscopy

37. TRUFILL® n-BCA Procedure Set-up
Inject TRUFILL n-BCA mixture through microcatheter

38. Microcatheters PROWLER® Microcatheter family.
TRUFILL ® n-BCA is compatible with:
PROWLER® Microcatheter family.
PROWLER SELECT ® Microcatheter family.
TRANSIT® Microcatheter family
RAPIDTRANSIT® Infusion catheter
MASSTRANSIT® Max ID catheter
TRANSIT® Microcatheter