Embolization of High Flow Arteriovenous Malformations: Experience with Use of Superabsorbent Polymer Microspheres

doi:10.1016/S1051-0443(07)61954-X

Journal of Vascular and Interventional Radiology

Volume 13, Issue 11, November 2002, Pages 1125-1133

https://doi.org/10.1016/S1051-0443(07)61954-X Get rights and content

PURPOSE

To determine efficacy, safety, and requirements for adjunctive embolization or surgery in the treatment of symptomatic arteriovenous malformations (AVMs) with superabsorbent polymer microsphere (SAP-MS) particles.

MATERIALS AND METHODS

SAP-MS particles (sodium acrylate and vinyl alcohol copolymer) are nonbiodegradable spheres with a precisely calibrated diameter. SAP-MS particles swell by absorbing fluids and become soft and deformable. Twenty-five patients (16 men, nine women; mean age, 32 y; range 12–66 y) with symptomatic facial (n = 5), upper-(n = 8) and lower-(n = 12) extremity AVMs were treated primarily (n = 23) or preoperatively (n = 2) by transarterial embolization (TAE) treatment with use of SAP-MS particles. Direct puncture embolization (DPE; n = 4) and/or surgical intervention (n = 5; ie, skin graft, resection, or amputation) were required. Surgical specimens from the resected (n = 2) and the amputated (n = 2) patients were evaluated histologically. Follow-up study, including clinical findings and imaging studies, was performed at intervals ranging from 3 months to 1 year. Clinical outcome was evaluated retrospectively, depending on the subjective improvement of symptoms and signs, according to the medical records.

RESULTS

Seventy-two TAEs (range, 1–11; mean, 2.8) and 12 DPEs (range, 1–3; mean, 2.4) were performed during the mean follow-up period of 38 months (range, 7–110 mo). Twenty patients (80%) experienced symptom improvement by embolotherapy alone (n = 17) or in combination with surgery (n = 3). One lip and two finger AVMs were totally removed by surgical excision or amputation after TAE treatment. In diffuse upper-(n = 1) and lower-(n = 1) extremity AVMs, the symptoms were uncontrolled. No nerve injury or skin necrosis was observed after TAE treatment with SAP-MS particles. Mucosal necrosis was induced by DPE with ethanol in one patient. Histologically, SAP-MS particles penetrated intralesional vessels and conformed to the vessel lumen, resulting in tight vessel occlusion. Minimal perivascular reaction was observed.

CONCLUSION

SAP-MS particles were used safely in TAE treatment of AVM. TAE treatment with use of SAP-MS particles was suitable for certain symptomatic AVMs, but diffuse AVMs remain a challenge and a combination of alternative methods will be necessary for further strategy.

Section snippets

Embolic Material

The SAP-MS (sodium acrylate and vinyl alcohol copolymer; Fig 1)isan embolic agent designed for use in the treatment of hypervascular tumors and AVMs. This material is a nontoxic and nonbiodegradable solid particle with a spherical shape. The particle size is calibrated in increments of approximately 50 μm (range, 53–350 μm; ie, 53–106,106 –150,150 –212,212–250, 250 –300,300 –350 μm). The SAP-MS absorbs fluids and swells within several minutes. The diameter of a SAP-MS particle in an ionic

RESULTS

Seventy-two TAE procedures were performed in all patients (range, 1–11, mean, 2.8 per patient) and 12 DPE procedures were performed in four patients (range, 1–3, mean, 1.8 per patient). SAP-MS particles were used in 71 of 72 TAE procedures (99%). In only one TAE procedure in one patient with LE-AVM, SAP-MS particles were not used because of a large arteriovenous fistula that was occluded with coils. SAP-MS particles were always easily delivered through a microcatheter and no catheter occlusion

UE-AVMs

In UE-AVMs (n = 8), pain (n = 5) and swelling (n = 8) were dominant symptoms. Intractable ulceration was seen in three cases and was accompanied by bleeding in two cases. In two cases with finger AVM, TAE treatment failed to improve the symptoms and both fingers were amputated. In one case of hand AVM, the lesion was prominent on the palm and severely painful. TAE treatment followed by DPE of the nidi with use of 1% polidocanol resulted in shrinkage of the lesion with pain relief. In three

LE-AVMs

In LE-AVMs (n = 12), pain (n = 10) and swelling (n = 11) were dominant symptoms in addition to skin ulcer (n = 4), bleeding (n = 1), and discoloration (n = 1). Pain relief was obtained by embolotherapy alone in nine cases and all of these patients walked well without restriction. Ulcer was intractable in two cases. In one case of foot AVM, the infiltrative diffuse AV shunting was noted on DSA. The painful ulcer was not controlled by TAE treatment and the patient was lost at 21-month follow-up

DISCUSSION

Efficacy of transarterial or direct puncture embolization for AVMs has been reported with use of various embolic agents including PVA (13, 14, 15, 16, 17), NBCA (7, 18, 19), ethanol (8), and others (20, 21). Although most of them were considered to be “effective” in short-to mid-term follow-up, there have been few reports describing long-term efficacy of each agent.

In the current study, the authors described their experience with use of SAP-MS particles in the management of facial and extremity

Acknowledgments

The authors thank Robert I. White, Jr., MD, for his editorial assistance, and Saki Osuga, MD, Fumiaki Isohashi, MD, and Ms. Yukari Tanaka for their help in the preparation of this manuscript.

References (37)

J Upton et al.
Vascular malformations of the upper limb: a review of 270 patients
J Hand Surg [Am]
(1999)
HH Trout
Management of patients with hemangiomas and arteriovenous malformations
Surg Clin North Am
(1986)
RI White et al.
Long-term outcome of embolotherapy and surgery for high-flow extremity arteriovenous malformations
J Vasc Interv Radiol
(2000)
AT Drooz et al.
Quality improvement guidelines for percutaneous transcatheter embolization
J Vasc Interv Radiol
(1997)
KW Dickey et al.
Management of large high-flow arteriovenous malformations of the shoulder and upper extremity with transcatheter embolotherapy
J Vasc Interv Radiol
(1995)
JS Pollak et al.
The use of cyanoacrylate adhesives in peripheral embolization
J Vasc Interv Radiol
(2001)
BB Lee et al.
New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation
J Vasc Surg
(2001)
JB Mulliken et al.
Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics
Plast Reconstr Surg
(1982)
JB Mulliken et al.
Vascular birthmarks: hemangioma and malformations
(1988)
C Olcott et al.
Intra-arterial embolization in the management of arteriovenous malformations
Surgery
(1976)

JM Griffin et al.

Congenital arteriovenous malformations of the upper extremity

Plast Reconstr Surg

(1978)

WF Yakes

Diagnosis and management of vascular anomalies

S Hori et al.

A new embolic material: superabsorbent polymer microsphere and its embolic effects

Jpn J Intervent Radiol

(1996)

K Osuga et al.

Embolic effects of superabsorbent polymer microsphere (SAP-MS); histopathological studies

Radiology

(1998)

Recommendations guiding doctors in clinical research. Adopted by the World Medical Association in 1964

Wis Med J

(1967)

AS Gomes et al.

Congenital arteriovenous malformations. The role of transcatheter arterial embolization

Arch Surg

(1983)

DM Widlus et al.

Congenital arteriovenous malformations: tailored embolotherapy

Radiology

(1988)

M Komiyama et al.

Embolization in high-flow arteriovenous malformations of the face

Ann Plast Surg

(1992)

Cited by (70)

Intraoperative Neuromonitoring during Peripheral Arteriovenous Malformation Embolization
2023, Journal of Vascular and Interventional Radiology
To evaluate whether intraoperative neuromonitoring (IONM), including pre-embolization lidocaine injection challenge (“provocative testing”) is associated with reduced risk of irreversible nerve injury during embolization of peripheral arteriovenous malformations (AVMs).
Medical records of patients with peripheral AVMs who underwent embolotherapy with IONM with provocative testing between 2012 and 2021 were reviewed retrospectively. Data collected included patient demographic characteristics, AVM location and size, embolic agent used, IONM signal changes after lidocaine and embolic agent injections, postprocedural adverse events, and clinical outcomes. Decisions regarding whether embolization would proceed at specific locations were based on IONM findings after the lidocaine challenge and as embolization proceeded.
A cohort of 17 patients (mean age, 27 years ± 19; 5 women) who underwent 59 image-guided embolization procedures with adequate IONM data was identified. No permanent neurologic deficits occurred. Transient neurologic deficits were observed in 3 patients (4 sessions), comprising skin numbness (2 patients), extremity weakness (1 patient), and extremity weakness and numbness (1 patient). All neurologic deficits resolved by postoperative day 4 without additional treatment.
IONM, including provocative testing, during AVM embolization may minimize potential nerve injury.
Ultrasonication-induced and diluent-assisted suspension polymerization for size-controllable synthesis of polydimethylsiloxane droplets
2022, Colloids and Surfaces A: Physicochemical and Engineering Aspects
Submicroscale polydimethylsiloxane (PDMS) spheres are emerging as a promising solution for a variety of engineering applications due to their unique material properties and size. It is, however, still considered as challenging to produce submicroscale PDMS droplets. This leads to the need for development of a deterministic method for producing size-controllable, monodisperse PDMS droplets and, by extension, comprehensive understanding of the physicochemical players and processes involved in the synthesis method. Here, we develop an ultrasonication-induced and diluent-assisted (UIDA) suspension polymerization process to achieve the scalable synthesis of monodisperse PDMS droplets. The UIDA suspension polymerization process is essentially the same as conventional suspension polymerization processes except ultrasonic agitation and organic diluent addition. The use of ultrasonication is intended to controllably reduce the size of PDMS droplets, while the addition of a diluent to PDMS is designed to enhance the monodispersity of PDMS droplets (major) and decrease their size (minor). First, we explore the dependence of PDMS droplet size and polydispersity on rudimentary factors such as stabilizer (i.e., polyvinyl alcohol (PVA)), magnetic stirring, ultrasonication, diluent (i.e., benzene), and synthesis vessel. Next, a time-variant change in the size and size distribution of PDMS droplets under UIDA suspension polymerization process are investigated by deconvoluting the droplet dispersity in size into two components, each of which is described using an envelope of the log-normal distribution. The main cause of a bimodal distribution is also identified. Finally, we demonstrate the applicability of PDMS droplets in altering the hydrodynamic properties of polymer surfaces by fabricating a set of rose petal-inspired substrates through evaporation coating of PDMS droplets on flat PDMS surfaces. The findings of this study will lead to better understanding of suspension polymerization for synthesizing monodisperse submicroscale droplets made of thermosetting polymers.
Embolization Techniques for Arteriovenous Malformations in Parkes-Weber Syndrome
2020, Annals of Vascular Surgery
Multiple high-flow arteriovenous malformations (AVMs) are the hallmark of Parkes-Weber syndrome (PWS). Surgical resection has historically shown poor outcomes with PWS. The aim of this study was to assess the management of PWS in the current era.
A retrospective review was performed from 2004 to 2017 on all patients presenting to a single institution for the management of PWS. Presentation, techniques, complications, and outcomes were reviewed.
Fourteen patients (50% male) with PWS were seen at our institution, and mean age was 19.9 years (range, 4.7–68.8). The lower extremity was affected in 12 (86%) and the upper extremity in 2 (14%) patients. All patients presented with pain and swelling in the affected limb. Seven (50%) patients presented with ulcers, of which 3 (43%) had extensive wounds. Five (36%) patients had echocardiographic evidence of high-output cardiac failure. All patients underwent angiography with the intention to treat. Three (21%) patients were found to have diffuse arteriovenous communication with no discrete AVM nidus and thus did not undergo intervention. The remaining 11 (79%) patients underwent transcatheter embolization of the AVM's arterial inflow. Six (55%) patients required multiple or staged inflow embolization procedures, with a mean of 3.3 (range, 1–10) interventions. Thirty-two arterial embolization procedures were performed in total. n-Butyl-2-cyanoacrylate (nBCA) adhesive was used in 22 (69%), microspheres in 8 (25%), and a combination of coils and nBCA adhesive in 2 (6%) cases. Technical angiographic success was seen in all patients. Six (55%) patients also had interventions to treat the venous component of the malformation, either concomitantly or during a separate procedure. This included radiofrequency ablation in 1 (17%), coil embolization in 1 (17%), sodium tetradecyl sulfate (STS) sclerotherapy in 2 (33%), and a combination of STS, coil embolization, and vein stripping in 2 (33%) patients. Ten (91%) patients experienced a partial response and 1 (9%) patient experienced no response to treatment. No patients had a complete response, as expected with the diffuse nature of this disease. There were no periprocedural complications. Two of 3 patients with complex wounds required major amputations for gangrene, including one above-knee and one below-knee amputation at 128 months and 66 months after the index procedure, respectively.
AVMs in PWS can be successfully treated by a transcatheter approach. Multiple interventions are usually required. Patients with extensive wounds remain at risk for loss of limb.
Case Report of Ethanol and Cyanoacrylate Embolisation of a Recurrent Uncontrollable Torrentially Bleeding Arteriovenous Malformation of the Finger
2018, EJVES Short Reports
Citation Excerpt :
Use of glue or coils as embolic agents have been extensively described but are rarely curative, and also associated with complications. Glue has been shown to be a non-permanent embolic agent with evidence of recanalization and neovascular recruitment, even after complete occlusion.5,6 Coils have been placed in the AVM draining veins in hope of reducing arteriovenous shunting and the amount of ethanol required for obliteration, however results have been less that ideal.7
In general, arteriovenous malformations (AVMs) are extremely rare, with an incidence of only 1 in 100,000. They are rarer still in the hands and present variably with bleeding, heaviness, a pulsatile mass, pain, ulceration, or necrosis.
The case of a 25 year old man with a rapidly bleeding right thumb AVM is presented. Bleeding was torrential and life threatening within a matter of seconds. He had previously undergone surgical ligation and embolisation twice at another centre, without success. At presentation, he had no thumb function and the bones of the thumb were exposed. An angio-embolisation was performed with ethanol and cyanoacrylate as the embolic agent. This was done using direct puncture into the AVM and also with a transarterial approach with microcatheters inserted into various unnamed branches feeding the AVM. Non-target embolisation and reflux was prevented by deploying a pneumatic tourniquet and mechanical elastic bands to confine the flow of the embolic agents within the AVM. Re-aspiration of the embolic agent post-embolisation was also performed to prevent local/systemic ethanol toxicity. Haemostasis was achieved without the need for further compression. A right thumb disarticulation was subsequently performed and the patient expressed great satisfaction with the outcome.
AVMs in the hand are particularly challenging to treat owing to the need to preserve function of the myriad tissues and structural units that enable the many hand movements involved in activities of daily living. Even a partial loss of function may be disabling or poorly tolerated. The mainstays of treatment are embolisation, sclerotherapy, and surgical ligation/resection, all of which carry the potential for ischaemic injury to muscle and soft tissue. A holistic approach to management is desirable prior to selecting the appropriate management plan.
Poly(acrylic acid) microspheres loaded with superparamagnetic iron oxide nanoparticles for transcatheter arterial embolization and MRI detectability: In vitro and in vivo evaluation
2017, International Journal of Pharmaceutics
To develop embolic microspheres with MRI detectability, superparamagnetic iron oxide nanoparticles (SPIONs) were synthesized and mixed with monomer of acrylic acid to prepare SPIONs-loaded polymerized microspheres (SPMs) by inverse suspension polymerization method. The SPMs were evaluated for the ability of embolization by investigating the morphology, particle size, elasticity and renal arterial embolization to rabbits. Meanwhile, the loading of SPIONs was verified by optical microscope, transmission electron microscope, Fourier transform infrared spectrum, vibrating sample magnetometer, X-ray diffraction and X-ray photoelectron spectroscopy, and the content of SPIONs in SPMs was measured quantitatively. Furthermore, the MRI detectability of SPMs was testified in gel phantom, mice and rabbits respectively by a clinical 3.0 T MRI scanner. The results revealed the SPMs were potential MRI detectable embolic microspheres for improving the effectiveness and safety of embolotherapy in the future.
Unusual Case of Parkes Weber Syndrome with Aneurysm of the Left Common Iliac Vein and Thrombus in Inferior Vena Cava
2015, Annals of Vascular Surgery
Citation Excerpt :
In addition, Giuseppe Straface reported case of 35-year-old male patient who was treated with repeated coil embolization, which resulted in partial shunting reduction.11 Nevertheless, some data showed that usage of superabsorbent polymer microspheres for embolization failed to control the shunting when multiple potent AV fistulas are present.12 In addition, we debate that risk of pulmonary embolism because of the thrombus in the vena cava that is present in our patient could be significantly reduced by placing vena cava filter.

View all citing articles on Scopus

: None of the authors has identified a conflict of interest.

View full text

Embolization of High Flow Arteriovenous Malformations: Experience with Use of Superabsorbent Polymer Microspheres

PURPOSE

MATERIALS AND METHODS

RESULTS

CONCLUSION

Section snippets

Embolic Material

RESULTS

UE-AVMs

LE-AVMs

DISCUSSION

Acknowledgments

J Hand Surg [Am]

Surg Clin North Am

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Surg

Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics

Plast Reconstr Surg

Vascular birthmarks: hemangioma and malformations

Intra-arterial embolization in the management of arteriovenous malformations

Surgery

Congenital arteriovenous malformations of the upper extremity

Plast Reconstr Surg

Diagnosis and management of vascular anomalies

A new embolic material: superabsorbent polymer microsphere and its embolic effects

Jpn J Intervent Radiol

Embolic effects of superabsorbent polymer microsphere (SAP-MS); histopathological studies

Radiology

Recommendations guiding doctors in clinical research. Adopted by the World Medical Association in 1964

Wis Med J

Congenital arteriovenous malformations. The role of transcatheter arterial embolization

Arch Surg

Congenital arteriovenous malformations: tailored embolotherapy

Radiology

Embolization in high-flow arteriovenous malformations of the face

Ann Plast Surg