Endovascular treatment ofarterio-venous malformations:

how to treat lesions with different angioanatomy?

LINC 2019

Leipzig, Germany, 23. January 2019

Walter A. Wohlgemuth

University Clinic and Policlinic of Radiology

Martin-Luther University Halle-Wittenberg, Germany

Conflicts of interest

Scientific grants:Siemens, Phillips, ab medica, ev3/covidien/medtronic, itm Flowmedical, Toshiba, Cook, W. L. Gore

Lectures: ev3/covidien/medtronic, Biotronic, St Jude Medical, Abbott, Siemens, ab medica, Boston Scientific, itm Flowmedical, Terumo, W. L. Gore

Consulting:1st WITiG, itm Flowmedical, Siemens, ev3/covidien/medtronic, ab medica

Proctoring:W. L. Gore, ev3/covidien/medtronic, ab medica

Angiographic classification of AVM

Type I Arterio-venous fistula Up to 3 direct fistulas withoutcircumscribed nidus

Type II Arteriolo-venousMalformation

Many feeding arteries and onedominant draining vein(DOV = dominant outflow vein)

Type IIIa Arteriolo-venulousMalformation

Non-dilated, microfistulous Nidus

Type IIIb Arteriolo-venulousMalformation

Dilated Nidus

DOV

Cho et al. J Enodvasc Ther 2006;13:527–538 Uller Wibke, Müller-Wille René, Wohlgemuth Walter A. Diagnostik und Klassifikation von Gefäßmalformationen. Interventionelle Radiologie Scan 2013; 3: 235-248

Type I

Arterio-venous fistula

Type I

DOV

A V

Arteriolo-venous Malformation with DOV

Type II

Type IIIa

Arteriolo-venulous Malformation(microfistulous with non-dilated drainage)

Type IIIb

Arteriolo-venulous Malformation(dilated drainage)

A V

Right-sided pelvic AVM, Type II with DOV, MRA in 2018Massive progress, venous flow-related aneurysm enlargement

Very painful dilated draining veins at perineum

Transvenous retrograde injection: 2 venous drainages Good chance to occlude the outflow

Complete occlusion in one session withvenous outflow occlusion and EVOH

Residual AVM type III b after EVOH embolisation

„Finishing“ with direct-punctureethanol

Ulcerationhealed after 4 months withethanolinjections

Endovascular treatment of peripheral AVM

• According to angio anatomy• Type I (AVF), e. g. pulmonary AVM/AVF in HHT Quite simple (Coils, AVP)

• Type II with dominant venous outflow transvenous + retrograde treatment options Good long-term results when venous outflow occluded EVOH, as adjunct: coils/AVP for flow-modulation

• Type III, diffuse, net-like „Nidus“, multiple venous drainages Direct puncture, i.a., i.v. Difficult to treat EVOH firstline, „finishing“ with ethanolMEK1-Inhibitors, MAP2K1 pathway modulators (?) Sometimes palliative results

• Wrong technique worsens situation (PVA, coils etc.) !

Müller-Wille R, Wildgruber M, Sadick M, Wohlgemuth WA. Vascular Anomalies (Part II): Interventional Therapy of Peripheral Vascular Malformations.Fortschr Röntgenstr 2018; 190:927-937

Wohlgemuth Walter A, Müller-Wille René, Teusch Veronika, Dudeck Oliver, Cahill Anne Marie, Alomari Ahmad, Uller Wibke. The retrograde transvenous push-through method: a novel treatment of peripheral arteriovenous malformations with dominant venous outflow. Cardiovasc Intervent Radiol 2015; 38: 623-631

Summary

• AVM treatment. angioanatomy decides agent

– Type I (e.g. in HHT): plug, coil

– Type II (with DOV): transvenous occlusion

– Type III (nidus as network): EVOH, finishing withethanol

• Be familiar with all agents

Univ.-Prof. Dr. Dr. Walter A. Wohlgemuth1) University Clinic and Policlinic of Radiology, Martin-Luther University Halle-Wittenberg, Germany

2) German Interdisciplinary Society of Vascular Anomalies

www.compgefa.de

Endovascular treatment ofarterio-venous malformations:

how to treat lesions with different angioanatomy?

LINC 2019

Leipzig, Germany, 23. January 2019

Walter A. Wohlgemuth

University Clinic and Policlinic of Radiology

Martin-Luther University Halle-Wittenberg, Germany