K.E.M. Radiology
K.E.M. Radiology
Patients First!
Patients First!
Embedded Files
Welcome to the Academic and Educational pages of the
Welcome to the Academic and Educational pages of the
Department of Radiology
Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Retrograde transvenous glue embolization via the great saphenous vein for a plantar arteriovenous malformation with a non-healing ulcer after failed transarterial embolization
Retrograde transvenous glue embolization via the great saphenous vein for a plantar arteriovenous malformation with a non-healing ulcer after failed transarterial embolization
Contributed by : Shrishti Patil
Contributed by : Shrishti Patil
Introduction:
Introduction:
Peripheral arteriovenous malformations (AVMs) are high-flow congenital vascular anomalies in which a nidus of abnormal arteriovenous connections replaces the normal capillary bed. They enlarge slowly and progress through the Schobinger stages, from quiescence to expansion, destruction (pain, ulceration, bleeding) and, finally, decompensation with high-output cardiac failure. [1, 2, 3] Complete eradication of the nidus is the only durable treatment, because incomplete treatment leaves a stimulus for recurrence and recruitment of collaterals. [4, 5]
Peripheral arteriovenous malformations (AVMs) are high-flow congenital vascular anomalies in which a nidus of abnormal arteriovenous connections replaces the normal capillary bed. They enlarge slowly and progress through the Schobinger stages, from quiescence to expansion, destruction (pain, ulceration, bleeding) and, finally, decompensation with high-output cardiac failure. [1, 2, 3] Complete eradication of the nidus is the only durable treatment, because incomplete treatment leaves a stimulus for recurrence and recruitment of collaterals. [4, 5]
Endovascular embolization is the first-line treatment for most symptomatic extremity AVMs. Embolic agents used include ethanol, N-butyl cyanoacrylate (NBCA, glue), ethylene vinyl alcohol copolymer (Onyx), particles and coils. The transarterial route is the most familiar, but proximal arterial occlusion and incomplete nidal penetration promote recruitment of collaterals and recurrence. The transvenous (retrograde) route, often aided by flow control, allows the embolic agent to be delivered directly into the nidus and the proximal draining vein. [6, 7, 8, 9]
Endovascular embolization is the first-line treatment for most symptomatic extremity AVMs. Embolic agents used include ethanol, N-butyl cyanoacrylate (NBCA, glue), ethylene vinyl alcohol copolymer (Onyx), particles and coils. The transarterial route is the most familiar, but proximal arterial occlusion and incomplete nidal penetration promote recruitment of collaterals and recurrence. The transvenous (retrograde) route, often aided by flow control, allows the embolic agent to be delivered directly into the nidus and the proximal draining vein. [6, 7, 8, 9]
This report describes a 15-year-old girl with a plantar AVM of the left foot and a non-healing ulcer, despite three sessions of transarterial embolization (two with glue and one with ethanol). Retrograde transvenous glue embolization through the great saphenous vein (GSV), the dominant outflow vein, was then performed and resulted in significant ulcer healing without major complications.
This report describes a 15-year-old girl with a plantar AVM of the left foot and a non-healing ulcer, despite three sessions of transarterial embolization (two with glue and one with ethanol). Retrograde transvenous glue embolization through the great saphenous vein (GSV), the dominant outflow vein, was then performed and resulted in significant ulcer healing without major complications.
The case highlights the role of the transvenous route when transarterial embolization fails. [9, 10].
The case highlights the role of the transvenous route when transarterial embolization fails. [9, 10].
Case presentation:
Case presentation:
Case presentation
Case presentation
A 15-year-old girl presented with a left foot AVM and a chronic ulcer over the plantar aspect of the foot (Figure 1). She had previously undergone three sessions of transarterial embolization elsewhere: glue embolization in 2010 and 2011, and alcohol embolization in 2013. Despite these three sessions, the ulcer had not healed.
A 15-year-old girl presented with a left foot AVM and a chronic ulcer over the plantar aspect of the foot (Figure 1). She had previously undergone three sessions of transarterial embolization elsewhere: glue embolization in 2010 and 2011, and alcohol embolization in 2013. Despite these three sessions, the ulcer had not healed.
Figure 1: Photograph of the left foot showing an arteriovenous malformation with a chronic ulcer over the plantar aspect, after three sessions of transarterial embolization
She had previously undergone three sessions of transarterial embolization elsewhere: glue embolization in 2010 and 2011, and alcohol embolization on 24 July 2013. Despite these three sessions, the ulcer did not heal.
She had previously undergone three sessions of transarterial embolization elsewhere: glue embolization in 2010 and 2011, and alcohol embolization on 24 July 2013. Despite these three sessions, the ulcer did not heal.
Radiological findings:
Radiological findings:
Imaging findings:
Imaging findings:
DSA of the left lower limb demonstrated a plantar AVM nidus, with the ulcer lying directly over the nidus (Fig. 2 and 3). The posterior tibial artery (PTA) and the anterior tibial artery (ATA) were the feeding vessels. There was a prominent draining vein, and the great saphenous vein (GSV) was the dominant outflow vein. Serial angiographic images from the transarterial alcohol embolization session in 2013 are shown in Figures 4 to 6.
DSA of the left lower limb demonstrated a plantar AVM nidus, with the ulcer lying directly over the nidus (Fig. 2 and 3). The posterior tibial artery (PTA) and the anterior tibial artery (ATA) were the feeding vessels. There was a prominent draining vein, and the great saphenous vein (GSV) was the dominant outflow vein. Serial angiographic images from the transarterial alcohol embolization session in 2013 are shown in Figures 4 to 6.
Figure 2: Arteriography of the left foot and ankle showing the posterior tibial artery (PTA) and the anterior tibial artery (ATA) supplying the plantar AVM nidus.
Figure 3: Arteriography of the left foot and ankle showing the great saphenous vein (GSV) as the dominant outflow vein, and the ulcer site at the AVM nidus.
Figures 4, 5 and 6: Serial angiographic images during transarterial alcohol embolization of the nidus, showing the nidus .
Interventional technique:
Interventional technique:
Retrograde transvenous glue embolization of the plantar AVM nidus through the great saphenous vein (GSV) was planned after failure of three sessions of transarterial embolization [6,7,10]
Retrograde transvenous glue embolization of the plantar AVM nidus through the great saphenous vein (GSV) was planned after failure of three sessions of transarterial embolization [6,7,10]
Pre-procedural planning:
Pre-procedural planning:
• Previous angiograms showed the feeding arteries (PTA, ATA), a plantar nidus with the ulcer over it, and the GSV as the dominant outflow vein (Figures 2 and 3)
• Previous angiograms showed the feeding arteries (PTA, ATA), a plantar nidus with the ulcer over it, and the GSV as the dominant outflow vein (Figures 2 and 3)
• Failure of three transarterial sessions to heal the ulcer prompted a change to the transvenous route
• Failure of three transarterial sessions to heal the ulcer prompted a change to the transvenous route
• Informed consent
• Informed consent
• Pre anesthetic work up, antibiotic prophylaxis, and baseline investigations.
• Pre anesthetic work up, antibiotic prophylaxis, and baseline investigations.
Approach:
Approach:
Retrograde transvenous approach through the GSV, the dominant outflow vein of the AVM at the ankle region.
Retrograde transvenous approach through the GSV, the dominant outflow vein of the AVM at the ankle region.
Step 1: Venous access and venography
Step 1: Venous access and venography
The GSV, the dominant outflow vein, was accessed and an H1 catheter and progreat microcatheter was advanced retrograde towards the nidus
The GSV, the dominant outflow vein, was accessed and an H1 catheter and progreat microcatheter was advanced retrograde towards the nidus
Step 2: Glue embolization of the nidus
Step 2: Glue embolization of the nidus
Glue was delivered retrogradely through the GSV into the nidus under fluoroscopic guidance (Figures 7 and 8).
Glue was delivered retrogradely through the GSV into the nidus under fluoroscopic guidance (Figures 7 and 8).
Post-procedure course
Post-procedure course
• The ulcer showed significant healing after transvenous glue embolization (Figure 9), in contrast to the lack of healing after three sessions of transarterial embolization
• The ulcer showed significant healing after transvenous glue embolization (Figure 9), in contrast to the lack of healing after three sessions of transarterial embolization
• No major complication was encountered
• No major complication was encountered
Figure 7,8:Image obtained during retrograde transvenous glue embolization through the great saphenous vein (GSV), showing the radio-opaque glue cast within the nidus.
Figure 9: Clinical photograph of the plantar ulcer after retrograde transvenous glue embolization, showing significant healing
Discussion
Discussion
Extremity AVMs are among the most difficult vascular anomalies to treat. They are classified as high-flow lesions under the ISSVA scheme, and the Schobinger staging system correlates with clinical behaviour: pain, ulceration and bleeding mark stage III [2,3]. Plantar lesions are especially problematic, because weight-bearing and repeated trauma sustain ulceration, and because ischaemic steal and venous hypertension impair healing. Extracranial AVMs recur frequently after incomplete treatment, and recurrence is typically driven by residual nidus and recruited collaterals [4]
Extremity AVMs are among the most difficult vascular anomalies to treat. They are classified as high-flow lesions under the ISSVA scheme, and the Schobinger staging system correlates with clinical behaviour: pain, ulceration and bleeding mark stage III [2,3]. Plantar lesions are especially problematic, because weight-bearing and repeated trauma sustain ulceration, and because ischaemic steal and venous hypertension impair healing. Extracranial AVMs recur frequently after incomplete treatment, and recurrence is typically driven by residual nidus and recruited collaterals [4]
Why transarterial embolization alone may fail:
Why transarterial embolization alone may fail:
The nidus is the target of treatment, not the feeding arteries. Proximal arterial occlusion, or embolization that stops short of the nidus, reduces flow only temporarily, and it removes the arterial route for later treatment while collaterals reconstitute the nidus[4,5]. In this patient, three transarterial sessions (glue twice and ethanol once) did not heal the ulcer.
The nidus is the target of treatment, not the feeding arteries. Proximal arterial occlusion, or embolization that stops short of the nidus, reduces flow only temporarily, and it removes the arterial route for later treatment while collaterals reconstitute the nidus[4,5]. In this patient, three transarterial sessions (glue twice and ethanol once) did not heal the ulcer.
Embolic agent selection:
Embolic agent selection:
The ideal agent should produce permanent occlusion of the nidus, penetrate it adequately, be controllable, and carry a low risk of non-target injury. The commonly used agents differ in these respects:
The ideal agent should produce permanent occlusion of the nidus, penetrate it adequately, be controllable, and carry a low risk of non-target injury. The commonly used agents differ in these respects:
1. Absolute ethanol:
1. Absolute ethanol:
o Endothelial destruction and thrombosis, giving a low recurrence rate in experienced hands [11]
o Endothelial destruction and thrombosis, giving a low recurrence rate in experienced hands [11]
o Risk of skin and nerve injury, and systemic toxicity including cardiopulmonary collapse, related to serum ethanol levels [12]
o Risk of skin and nerve injury, and systemic toxicity including cardiopulmonary collapse, related to serum ethanol levels [12]
2. Glue (N-butyl cyanoacrylate, NBCA):
2. Glue (N-butyl cyanoacrylate, NBCA):
o Rapid polymerization on contact with blood, giving permanent occlusion
o Rapid polymerization on contact with blood, giving permanent occlusion
o Needs operator experience, because of catheter adhesion and non-target (including pulmonary) embolization
o Needs operator experience, because of catheter adhesion and non-target (including pulmonary) embolization
o Usually mixed with Lipiodol to adjust polymerization time and give radio-opacity
o Usually mixed with Lipiodol to adjust polymerization time and give radio-opacity
3. Ethylene vinyl alcohol copolymer (Onyx):
3. Ethylene vinyl alcohol copolymer (Onyx):
o Cohesive, non-adhesive, slow-injection agent with better control and deeper penetration [13]
o Cohesive, non-adhesive, slow-injection agent with better control and deeper penetration [13]
o Skin discoloration, and cost
o Skin discoloration, and cost
4. Coils and particles:
4. Coils and particles:
o Useful for proximal outflow control or large fistulae, but unsuitable as the sole agent for a nidus, because of recanalization and collateral recruitment
o Useful for proximal outflow control or large fistulae, but unsuitable as the sole agent for a nidus, because of recanalization and collateral recruitment
Transarterial vs transvenous approach:
Transarterial vs transvenous approach:
1. Transarterial approach:
1. Transarterial approach:
o Advantages: familiar route; directly accesses the feeding arteries; allows selective angiography
o Advantages: familiar route; directly accesses the feeding arteries; allows selective angiography
o Disadvantages: rapid flow carries the embolic agent past the nidus; tortuous, small feeders; loss of future arterial access; recruitment of collaterals if feeders are occluded proximally
o Disadvantages: rapid flow carries the embolic agent past the nidus; tortuous, small feeders; loss of future arterial access; recruitment of collaterals if feeders are occluded proximally
2. Transvenous (retrograde) approach through a dominant outflow vein [6,9]
2. Transvenous (retrograde) approach through a dominant outflow vein [6,9]
o Advantages: embolic agent is delivered directly into the nidus and the proximal draining vein; allows the nidus to be filled in a retrograde fashion; effective when arterial access is not feasible or has failed
o Advantages: embolic agent is delivered directly into the nidus and the proximal draining vein; allows the nidus to be filled in a retrograde fashion; effective when arterial access is not feasible or has failed
o Disadvantages: needs a favourable, accessible outflow vein; risk of embolic agent passing into the venous system and the lungs; risk of venous thrombosis and of venous congestion if outflow is occluded before the nidus is filled
o Disadvantages: needs a favourable, accessible outflow vein; risk of embolic agent passing into the venous system and the lungs; risk of venous thrombosis and of venous congestion if outflow is occluded before the nidus is filled
In this case, the GSV was the dominant outflow vein, and was therefore a logical conduit for retrograde embolization of the plantar nidus after failure of the transarterial route. Flow control (by tourniquet or balloon occlusion of the outflow vein) is often used to slow flow and to improve nidal penetration of the agent, and reduces the risk of non-target embolization[6,8]
In this case, the GSV was the dominant outflow vein, and was therefore a logical conduit for retrograde embolization of the plantar nidus after failure of the transarterial route. Flow control (by tourniquet or balloon occlusion of the outflow vein) is often used to slow flow and to improve nidal penetration of the agent, and reduces the risk of non-target embolization[6,8]
Outcomes and prognosis:
Outcomes and prognosis:
Treatment outcomes depend on the angiographic type of the AVM, the extent of nidal obliteration, and the stage of disease [7,14]. Complete cure is uncommon in extensive lesions, and long-term follow-up is needed, because recurrence can occur years after apparent success [4]. Healing of the ulcer and control of bleeding are the practical clinical goals in stage III disease.
Treatment outcomes depend on the angiographic type of the AVM, the extent of nidal obliteration, and the stage of disease [7,14]. Complete cure is uncommon in extensive lesions, and long-term follow-up is needed, because recurrence can occur years after apparent success [4]. Healing of the ulcer and control of bleeding are the practical clinical goals in stage III disease.
Complications:
Complications:
Complications of AVM embolization include skin and soft-tissue necrosis, nerve injury, pulmonary embolization of the embolic agent, deep venous thrombosis, and catheter entrapment with glue. Minor complications include local pain and swelling. Careful selection of agent, flow control and staged treatment reduce these risks [8,10].
Complications of AVM embolization include skin and soft-tissue necrosis, nerve injury, pulmonary embolization of the embolic agent, deep venous thrombosis, and catheter entrapment with glue. Minor complications include local pain and swelling. Careful selection of agent, flow control and staged treatment reduce these risks [8,10].
Conclusion:
Conclusion:
Retrograde transvenous glue embolization through the dominant outflow vein is a safe and effective option for a symptomatic extremity AVM that has failed transarterial embolization.
Retrograde transvenous glue embolization through the dominant outflow vein is a safe and effective option for a symptomatic extremity AVM that has failed transarterial embolization.
Key points from this case:
Key points from this case:
1. Patient selection: transvenous embolization is considered when transarterial treatment fails, or when a dominant, accessible outflow vein is present.
1. Patient selection: transvenous embolization is considered when transarterial treatment fails, or when a dominant, accessible outflow vein is present.
2. Target: the nidus, not the feeding arteries, must be treated to achieve durable control.
2. Target: the nidus, not the feeding arteries, must be treated to achieve durable control.
3. Technical approach: retrograde access through the GSV, the dominant outflow vein, allowed direct delivery of glue to the plantar nidus.
3. Technical approach: retrograde access through the GSV, the dominant outflow vein, allowed direct delivery of glue to the plantar nidus.
4. Embolic strategy: glue provides permanent occlusion but needs operator experience; ethanol is effective but carries a higher risk of tissue and systemic toxicity.
4. Embolic strategy: glue provides permanent occlusion but needs operator experience; ethanol is effective but carries a higher risk of tissue and systemic toxicity.
5. Outcome: the ulcer showed significant healing without a major complication.
5. Outcome: the ulcer showed significant healing without a major complication.
6. Follow-up: long-term clinical and imaging surveillance is needed, because AVMs can recur.
6. Follow-up: long-term clinical and imaging surveillance is needed, because AVMs can recur.
References
References
1. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 1982;69:412-22.
1. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 1982;69:412-22.
2. International Society for the Study of Vascular Anomalies. ISSVA classification of vascular anomalies [2018].
2. International Society for the Study of Vascular Anomalies. ISSVA classification of vascular anomalies [2018].
3. Kohout MP, Hansen M, Pribaz JJ, Mulliken JB. Arteriovenous malformations of the head and neck: natural history and management. Plast Reconstr Surg. 1998;102:643-54.
3. Kohout MP, Hansen M, Pribaz JJ, Mulliken JB. Arteriovenous malformations of the head and neck: natural history and management. Plast Reconstr Surg. 1998;102:643-54.
4. Liu AS, Mulliken JB, Zurakowski D, Fishman SJ, Greene AK. Extracranial arteriovenous malformations: natural progression and recurrence after treatment. Plast Reconstr Surg. 2010;125:1185-94.
4. Liu AS, Mulliken JB, Zurakowski D, Fishman SJ, Greene AK. Extracranial arteriovenous malformations: natural progression and recurrence after treatment. Plast Reconstr Surg. 2010;125:1185-94.
5. Lee BB, Baumgartner I, Berlien P, et al. Consensus document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management. Int Angiol. 2013;32:9-36.
5. Lee BB, Baumgartner I, Berlien P, et al. Consensus document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management. Int Angiol. 2013;32:9-36.
6. Jackson JE, Mansfield AO, Allison DJ. Treatment of high-flow vascular malformations by venous embolisation aided by flow occlusion techniques. Cardiovasc Intervent Radiol. 1996;19:323-8.
6. Jackson JE, Mansfield AO, Allison DJ. Treatment of high-flow vascular malformations by venous embolisation aided by flow occlusion techniques. Cardiovasc Intervent Radiol. 1996;19:323-8.
7. Cho SK, Do YS, Shin SW, et al. Arteriovenous malformations of the body and extremities: analysis of therapeutic outcomes and approaches according to a modified angiographic classification. J Endovasc Ther. 2006;13:527-38.
7. Cho SK, Do YS, Shin SW, et al. Arteriovenous malformations of the body and extremities: analysis of therapeutic outcomes and approaches according to a modified angiographic classification. J Endovasc Ther. 2006;13:527-38.
8. Rosen RJ, Nassiri N, Drury JE. Interventional management of high-flow vascular malformations. Tech Vasc Interv Radiol. 2013;16:22-32.
8. Rosen RJ, Nassiri N, Drury JE. Interventional management of high-flow vascular malformations. Tech Vasc Interv Radiol. 2013;16:22-32.
9. Yakes WF, Baumgartner I. Interventional treatment of arterio-venous malformations. Gefasschirurgie. 2014;19:325-30.
9. Yakes WF, Baumgartner I. Interventional treatment of arterio-venous malformations. Gefasschirurgie. 2014;19:325-30.
10. Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a multidisciplinary approach. J Vasc Surg. 2004;39:590-600.
10. Lee BB, Do YS, Yakes W, Kim DI, Mattassi R, Hyon WS. Management of arteriovenous malformations: a multidisciplinary approach. J Vasc Surg. 2004;39:590-600.
11. Do YS, Yakes WF, Shin SW, et al. Ethanol embolization of arteriovenous malformations: interim results. Radiology. 2005;235:674-82.
11. Do YS, Yakes WF, Shin SW, et al. Ethanol embolization of arteriovenous malformations: interim results. Radiology. 2005;235:674-82.
12. Mason KP, Michna E, Zurakowski D, Koka BV, Burrows PE. Serum ethanol levels in children and adults after ethanol embolization or sclerotherapy for vascular anomalies. Radiology. 2000;217:127-32.
12. Mason KP, Michna E, Zurakowski D, Koka BV, Burrows PE. Serum ethanol levels in children and adults after ethanol embolization or sclerotherapy for vascular anomalies. Radiology. 2000;217:127-32.
13. Numan F, Omeroglu A, Kara B, Cantasdemir M, Adaletli I. Embolization of peripheral vascular malformations with ethylene vinyl alcohol copolymer (Onyx). J Vasc Interv Radiol. 2004;15:939-46.
13. Numan F, Omeroglu A, Kara B, Cantasdemir M, Adaletli I. Embolization of peripheral vascular malformations with ethylene vinyl alcohol copolymer (Onyx). J Vasc Interv Radiol. 2004;15:939-46.
14. Park KB, Do YS, Kim DI, et al. Predictive factors for response of peripheral arteriovenous malformations to embolization therapy: analysis of clinical data and imaging findings. J Vasc Interv Radiol. 2012;23:1478-86.
14. Park KB, Do YS, Kim DI, et al. Predictive factors for response of peripheral arteriovenous malformations to embolization therapy: analysis of clinical data and imaging findings. J Vasc Interv Radiol. 2012;23:1478-86.
Figure 10: Clinical photograph of the plantar ulcer after retrograde transvenous glue embolization, showing significant healing.
I never De
An
An
Google Sites
Report abuse