Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes

Abstract

ObjectiveEmbolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs.Materials and MethodsWe performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed.ResultsA total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm3). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months).ConclusionPreoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.

In Vivo Feasibility of Arterial Embolization with Permanent and Absorbable Suture: The FAIR-Embo Concept

“…An additional bench-work needs to be done to demonstrate how the consistency and morphology of the sutures makes them easy to use through the catheter for an embolization. Anyway, silk sutures are already used for arterial embolization [7][8][9].…”

“…from 0.5 mm to 3 cm fragments through ordinary catheter and microcatheter. This silk suture allowed effective and safe embolization without increasing bleeding and inflammatory risk [7][8][9]. Besides, embolization cases described with silk suture do not report cases of recanalization.…”

“…To our knowledge, the suture embolization has only been made with the use of silk-based thread. This embolic material used in combination with PVA particles often using 6-0 size and 0.5 mm to 3 cm fragments through ordinary catheter and microcatheter allows effective and safe embolization without increasing bleeding and inflammatory risk [7][8][9].…”

Transcatheter embolization with Squid, combined with other embolic agents or alone, in different abdominal diseases: a single-center experience in 30 patients

“…In TL-F total liver function our series of 5 patients, AVMs embolization strategy was initially based on PVA particles to determine nidus or microcirculation hypoxia, followed by Squid-18 to occlude the feeding arteries. In AVMs, it is mandatory before Squid administration to embolize nidus using PVA particles or embosphere (Merit Medical, Jordan, Utah, USA): the lack of peripheral occlusion with proximal embolization alone can favor collaterals formation from other vessels predisposing to relapses and re-interventions (Conger et al, 2016). Furthermore, in the case of an acute iatrogenic arterial bleeding Squid was very useful in emergency to quickly and completely fill the ruptured artery that presented a large breach with significant extravasation of contrast.…”

Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem

“… 41) 42) Although radiosurgery is a conceptually attractive alternative to surgical resection of eloquent CCMs, the radiosurgery-induced complication rate is significantly higher for CCMs than for AVMs, and CCMs cannot be radiologically monitored for obliteration after radiosurgery. 3) 5) 6) 8) 9) 10) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 25) 26) 27) 28) 29) 30) 31) 32) 33) 34) 35) 36) 37) 43) 44) 49) 50) 52) 53) 56) 59) 63) 64) 65) 66) 67) 68) Instead, the proposed effect of radiosurgery on CCMs is a decreased risk of symptomatic hemorrhages, which is controversial due to temporal clustering of CCM hemorrhages. 4) Thus, surgical resection remains the gold standard of CCM intervention and is warranted for appropriately selected patients harboring thalamic and brainstem CCMs.…”