Prática de Shadowing: Embolization of AV Malformations: Tips and Tricks - Aprenda a falar inglês com o YouTube

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Hi.

I'd like to thank the organizers for inviting me here today.

So this is going to be a pretty quick review as well because it's kind of a complex topic.

So I'm going to focus mainly on the technical part of embolization procedures.

These are disclosures.

And so the AVM, as we all know,

are abnormal connections between arteries and veins.

Typically with the intervening nidus or collection of abnormal vessels with feeding arteries and draining veins.

They can be divided into different types,

the top being more fistulist-type connections,

which are a direct artery into a venous sac

and then going down to multiple arteries coming into a nidus and then an outflowing vein.

And these have been related to different genetic diseases,

such as hemorrhagic hereditary telangiectasia 1 and 2, capillary malformation AVM syndrome.

Then they—these do have genes associated with them,

but most AVMs are actually sporadic.

And then in, I am a neurointerventionalist,

so we divide our AVMs into many different types.

I'm not going to go over it very laboriously,

but depending on where it's located,

so in the cerebral matter itself,

peel malformations are ranging from nidal-type malformations to fistulas,

which occur mainly in pediatrics.

and galen malformations occur mainly in newborns.

And then there are malformations that are more fistulas

and acquired later in life that occur in the dura or lining of the brain.

And this can be found in the carotid cavernous region where you can also find direct fistulas from trauma.

And then there's a whole organization for spinal AVMs as well.

And so how, you know,

to get to the embolization part,

how do we close these malformations?

The focus and the goal really is to treat the nidus in the case of nidal aneurysms

and close this connection as well as in the fistula's connection,

the focus is really to get to the proximal part of the vein that's receiving the arteries and close that.

are sometimes used in these cases,

but actually less so because you really can only get to these medium-sized arteries or smaller,

even tinier arteries with coils,

so you can't really get good penetration into the nidus itself.

There have been use of sclerosing agents,

so taking a micro catheter sorry into a feeding artery injecting ethanol 100% ethanol to kind of burn the malformation

and and destroy it in that way but the more common uses liquid agents

and that can be there are really two

that are in use in the US right now there's NBC a which is a cyanoacrylate and then there's onyx

which is a polymer, and I'll go into those.

And then there's some neuroagents in development,

and these can be placed into the nidus or into the vein via a transarterial or a transvenous approach.

NBCA is closely related to crazy glue.

It's an adhesive, so it sticks to the arteries.

And the goals, as with any embolization of AVM,

is good penetration into the nidus.

And with NBCA, it is,

once it contacts the blood, it polymerizes very quickly.

And so you want to prevent proximal reflux along the catheter,

as prolonged contact with the catheter will cause adhesion to it.

And you can have a retained catheter or vessel injury when you try to pull it out.

Onyx was developed and approved by the FDA in the 1990s and actually in the mid-2000s.

And this is a copolymer of ethylene vinyl alcohol.

It's dissolved in a solvent, DMSO.

And then there's suspended micronized tantalum powder in it to achieve radio radio opacity,

so it needs to be shaken right before you inject it or else all the tantalum will settle out of it.

And then the traditional method of injecting onyx is to inject,

and it looks like this dark color because of the tantalum within it,

so you inject little bits along the tip of the microcatheter until you fill the proximal artery here,

refluxing a little bit along the catheter.

And then as soon as you create,

the goal of that is to create a plug within the proximal artery at the location of the tip of the catheter.

And then once you create that plug,

when you inject, it's going to go forward and penetrate into the nidus.

So like I said, a proximal plug is used,

and the catheter needs to be removed from the embolic cast at the end of the embolization.

So even though Onyx is not adhesive,

it can be, if you reflux too much along the catheter,

this can lead to a retained microcatheter as well,

just because of friction in trying to remove it.

And if you then pull too hard,

this can lead to rupture and hemorrhage.

So the tips and tricks,

I'm really just going to talk about a few newer techniques that we're using in the last few years.

And one of them is,

and it has to do with newer technology that's coming out.

So one is the use of the detachable tip microcatheter,

which is called the Apollo microcatheter.

And it's a single lumen catheter.

It has a tip that's actually held into a shaft here by pressure, by friction.

And this allows for a force being required to actually separate the two.

So it's less than a third of the force that you would need to actually break any other part of the catheter.

So it's thought that it's a more gentle force of retrieving the catheter.

And you basically just pull slowly and stretch and stretch until it detaches or the whole thing pulls out of the onyx.

And this catheter comes with two tips.

So this is the distal tip,

the proximal marker here is where the detachment zone is.

So you can't, if you're injecting and you reflux all the way to this point,

you have to stop because you're going to then glue that detachment zone in place.

And this is an example of a vertebral peel fistula.

So this is an AP view and a lateral view,

the vertebral artery in the neck,

and this fistula's connection to posterior fossa vein.

And this is a navigation of the Apollo catheter to the fistula.

You could see it in place,

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the distal marker and the proximal marker.

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And there you see an injection of NBCA.

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So this catheter can be used with both NBCA and ONIX.

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And in this case, it looks like the catheter was completely removed without detaching.

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So then in a second injection,

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another Apollo catheter was brought up to a second fistula site.

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And there's some injection of contrast showing the direct connection to the vein.

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And this is a video here.

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And this is high concentration of NBCA.

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So this really, if you were using any standard microcatheter,

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you would not keep it there that long because you'd be afraid of actually polymerizing and gluing the catheter in place.

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But because now that we have the detachable tip,

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we're more comfortable trying to get good penetration with NBCA.

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And so that's the injection.

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You can see more NBCA filling into the venous side of the fistula,

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and then pull and out.

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And then you can see kind of tiny here,

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but that's the distal tip, and that's the catheter.

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So it's actually detached, and the distal tip of it is left in place.

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So the advantages with Onyx,

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you make reflux purposefully to create a plug,

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so you know how much you can reflux.

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And with the NBCA, you have a controlled injection instead of trying to inject quickly and then pull it out.

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So this allows for better penetration.

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And then it requires less pressure to remove the catheter,

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so less chance of injuring.

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The disadvantage, it is a bit stiffer at the detachment zone,

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so the connection between the tip and the proximal microcatheter

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compared with the rest of the microcatheter and with some other softer microcatheters that we may use.

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And then we've had now two cases where on navigating the catheter without attempting to detach the tip,

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it's inadvertently detached in a proximal artery.

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So that's something that that if you're navigating in torturous anatomy, it can happen.

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And that's the tip.

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So the other thing that's come about is the development of DMSO compatible balloon microcatheters.

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So these are the SEPTR balloons.

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And it's just, it's a dual lumen catheter.

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So you have a lumen that you can inject onyx or glue or coils,

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whatever you want, whatever you're doing,

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and then a second port to inflate this balloon.

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And then this is a case,

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so this really allows for a really good penetration without having to worry about reflux or make a plug.

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So So this is a case of a maxillary arteriovenous malformation.

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This is the internal maxillary, the patient's maxilla.

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And you see this abnormal AVM, capillary-type AVM right here.

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And then this is the balloon catheter in place.

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So it's in this branch here.

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And this is the inflation of the balloon.

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So you create a plug just by inflating the balloon.

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It's very quick.

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And then you can achieve great penetration into the entire AVM.

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This required injection into a couple different feeders,

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but by using this technique,

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I was able to completely treat.

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And at the end of this treatment,

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there was no remaining shunting.

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The important thing when you're using Onyx is you have to be able to recognize abnormal and normal and know your,

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especially in the head and neck,

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you have to know where you're located.

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Avoid any abnormal connections to the internal carotid circulation

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or any normal connections that you might not see

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but you know are there because the onyx with this technique can penetrate into small collaterals that are otherwise closed.

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And then just as This is a last example.

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This is a 42-year-old man with headaches and tinnitus,

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and he got this MRA,

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which shows this markedly abnormal enlarged vessels on the left side of his head from external and as well internal circulation,

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and all going into the left transverse sinus.

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This is a typical dural arteriovenous fistula, and usually acquired.

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This is the MRA showing that fistula.

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You see some external carotid artery,

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occipital branches, middle meningeal branches,

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and then on angiography marked dilatation of these branches.

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And really on the CAT scan,

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we can see that they really all come down to this connection right here into the transverse sinus,

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or so we thought.

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However, when we closed that off,

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we realized that the fistulas were coming to multiple locations along that sinus.

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And this is one disadvantage of ONIX.

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So after you have to close such a complex malformation with multiple vessels,

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you're left with this sort of picture in which you can't really see anything afterwards.

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So that leads to my last point,

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which is the development of this new liquid embolic called Phil,

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which is currently approved in Europe.

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And this is going to be,

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it's going to have iodine attached to the copolymer.

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And so therefore that should absorb and it will be less radio-opaque when you come back for later treatments.

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And that's it.

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Thank you for your attention.

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