Percutaneous embolization of arteriovenous malformations at the plantar aspect of the foot

Abstract

Peripheral arteriovenous malformations (AVM) remain most challenging among various congenital vascular malformations to be treated. Here we present three illustrative patients with Yakes type IIIb and type IV AVM at the plantar aspect of the foot who were successfully treated by minimally invasive embolization. The value of the Yakes AVM classification system to guide the therapeutic decision making by directing specific therapeutic procedures to specific AVM types defined by their angioarchitecture is demonstrated. Direct percutaneous AVM puncture with coiling of aneurysmal outflow vein and subsequent ethanol embolization is shown. Finally, the report illustrates that several AVM types can coexist.

Arteriovenous malformation on the sole of the foot treated successfully by embolization

“…AVMs of the sole of the foot are rare and can cause disturbances in normal living activities [ 13 , 14 ]. Surgical excision of the AVM was the gold-standard treatment but is difficult because AVMs usually exist inside normal tissue, where the loss of their normal function is inevitable; in this case, it would mean a partial foot amputation.…”

“…To plan the optimal approach, predict therapeutic outcomes, and minimize non-target embolization of peripheral AVMs, classification by angiography is used. Various angiographic classifications of the nidus have been proposed [ 1 , 13 ]. The present case used Cho et al’s classification and included type II and IIIb lesions.…”

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

“…Superselective nidus penetration for delivery of the embolic agent of choice can be performed through the transarterial, transvenous, or direct puncture (DSE) routes. [1][2][3][4][5] In more complicated angioarchitectural varieties, a combination of these approaches may be necessary. The more conventional transarterial route is not always possible because of factors such as extreme tortuosity of feeding vessels, vasospasm, and presence of innumerable arterial feeders.…”

“…1,4,6,7,10 The Yakes AVM classification system provides a useful guide for treatment planning that may require retrograde and DSE primary treatment approaches (Table). 5,8,9,11 Whereas ultimately the route of therapy is determined by the experienced operator, certain AVM configurations lend themselves more effectively to certain therapeutic modalities over others. For example, Yakes Ia AVMs represent a more direct fistulous connection between the involved artery and vein.…”

“…The embolic agents used most commonly with DSE have been ethanol and n-butyl cyanoacrylate. 1,5 Another commonly used agent in AVM treatment is the slowly polymerizing agent Onyx (Covidien, Plymouth, Minn). It has been well described in both transarterial and, more rarely, retrograde transvenous approaches to AVM embolization.…”