Direct stick embolization of extremity arteriovenous malformations with ethylene vinyl alcohol copolymer

Abstract

Direct stick embolization (DSE) of high-flow peripheral arteriovenous malformations (AVMs) has previously been reported using n-butyl cyanoacrylate and ethanol. The use of ethylene vinyl alcohol copolymer (Onyx; Covidien, Plymouth, Minn) through this delivery route has been extremely limited, particularly in the peripheral interventional realm, owing to concerns about technique and conduit for delivery, skin discoloration, and ulceration. We describe three patients with relatively focal, symptomatic, congenital high-flow AVMs of the upper and lower extremity treated successfully by multifaceted approaches including transvenous coil embolization of the nidus venous outflow, transarterial embolization, and DSE of the AVM nidus with Onyx. Successful delivery of Onyx into the AVM nidus was achieved without nontarget embolization. Sustained symptomatic relief without recurrence or associated complications was achieved at 1 month, 3 months, and 6 months of follow-up. Nidus embolization is a key technical maneuver for optimal treatment of high-flow AVMs, although it is not always easily achievable by the transarterial route in more extensive, convoluted angioarchitectural varieties. With appropriate technical considerations and precautionary measures, Onyx can be safely and effectively delivered through DSE into the AVM nidus with satisfactory short-term and midterm clinical outcomes. This maneuver expands the armamentarium of the treating vascular surgeon facing complicated peripheral AVMs.

Endovascular treatment results and risk factors for complications of body and extremity arteriovenous malformations

“…In terms of ethanol toxicity and complications, a less toxic agent such as Onyx has been attempted as an embolic agent for AVM treatment. [7][8][9] Onyx showed favorable results in some small case series of AVM, but a large volume of data are required. A case of Onyx resorption and AVM recanalization has been reported in the literature.…”

“…Recently, ethylene vinyl alcohol copolymer (Onyx; ev3, Covidien, Plymouth, Minn) has been proposed. [7][8][9] However, the treatment of AVM remains highly challenging, with satisfactory results difficult to achieve for certain types of AVMs despite repeated treatment.…”

Surgical treatment of arteriovenous malformations of the buttock

“…-Embolization: Progress in interventional radiology has had an impact on the treatment of complications (percutaneous embolization) (4,5) and on stabilizing progression, but incomplete effectiveness on the underlying AVM persists (6,7,8). In our cohort, nine of 12 patients (75%) had previous embolization.…”

“…There are some older published papers related to surgical treatment of AVM of the buttock (1,2,4). One (1) identified the location of AVM in connective tissue.…”

“…For these reasons, numerous techniques of interventional radiology have been proposed such as arterial, trans venous or percutaneous embolization. (4,5,6,7,8))…”