Adenosine-induced transient circulatory arrest in transvenous embolization of cerebral arteriovenous malformations

Abstract

Due to advances in interventional techniques, the transvenous approach may present an effective treatment option for embolization of brain arteriovenous malformations (AVMs). Contrary to the transarterial method, the transvenous approach can only be utilized in a specific subset of patients and is not suitable as a standard procedure for all AVM lesions. While this technique can be helpful in certain patients, careful patient selection to ensure patient safety and favorable clinical outcomes is important. However, especially in high-flow AVMs, targeted deposition of embolic materials through a transvenous access can be challenging. Therefore, a temporary flow arrest may prove helpful. Transient cardiac arrest by use of adenosine has been applied in cerebrovascular surgery but is not common for endovascular embolization. Adenosine-induced arrest and systemic hypotension may be a feasible, safe method to reduce flow and help endovascular transvenous embolization of certain AVMs. Our study evaluated the efficiency and safety of adenosine-induced circulatory arrest for transvenous embolization of cerebral AVMs.

State of the Art in the Role of Endovascular Embolization in the Management of Brain Arteriovenous Malformations—A Systematic Review

“…For this reason, temporary flow arrest by either balloon occlusion or adenosine-induced circulatory arrest could facilitate and improve embolization [ 135 ]. Ghorbani et al tested the safety and efficacy of adenosine-induced circulatory arrest in the transvenous embolization of six patients with bAVMs and reported that at the 6-month follow-up, four patients had an mRS of 2 and two patients had an mRS of 1 [ 136 ]. Recently, Iosif et al described a novel approach to their previously reported transvenous method [ 137 ] that involved placing hypercompliant balloons intra-arterially for the selective occlusion of arterial feeders during ethylene vinyl copolymer (EVOH) transvenous injection [ 137 ].…”

Pediatric Cerebral Vascular Malformations : Current and Future Perspectives

“…Endovascular approaches can assist with the treatment of AVMs through better visualization for operative or radiation planning, perioperative reduction of high-flow pedicles to make surgery safer or – in some cases, such as VOGMs – complete cure through embolization alone [ 1 , 55 , 62 ]. Innovation continues in this field, including transvenous access and embolization, flow modulation (in which cardiac output can be altered pharmacologically or via cardiac pacing to attempt safer delivery of embolic agents) and the use of single or multiple intravascular balloons to regulate flow during procedures [ 15 , 18 , 24 , 28 , 38 , 40 ]. These advances also come with risk, including injury to unaffected vessels during the procedure, off-target embolization, radiation exposure (especially important in smaller children/infants) and the risk of unexpected hemorrhage resulting from re-routing of blood flow post-embolization [ 4 ].…”

Endovascular Management of Brain Arteriovenous Malformations

“…The original idea of Massoud et al of using compliant balloons in the main feeders to obtain temporary flow arrest and reduce intra-nidal pressure during TVE was successfully reported recently (84) and seems to be as effective as induced arterial hypotension. Alternatively, some authors advocate the use of adenosine-induced transient cardio-circulatory arrest for very high-flow bAVMs (85,86) to potentiate retrograde embolization during TVE and claim this to be safe in the few patients in which it was performed. Others, finally, advise employing rapid ventricular pacing reduce ventricular filling time (87).…”