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Treating arteriovenous malformations (AVM) using liquid embolic devices? Join Prof. Laurent Spelle and the expert panel from LINNC 2018 for this live intervention from the NEURI Center (Bicêtre University Hospital, France). Performed by Prof. Jacques Moret, assisted by Drs. Christian Mihalea (Romania) and Soheil Naderi (Iran) follow the case and an in-depth discussion on the treatment of AVMs in general, and the use of embolic devices in particular.
A 26-year-old female presents with sudden onset right hemiplegia and an AVM on examination. During the acute stage no action until day 6 when a decreased consciousness level requires decompressive craniectomy. The AVM is not removed at the same time as the hematoma and cranioplasty is not performed.
At 3-month follow-up, the patient still has mild persistent right hemiparesis and an mRS of 2 or 3. Prof. Spelle takes us through Prof. Moret’s strategy – an endovascular intervention to isolate the AVM employing a double arterial/venous approach where femoral access is used for the arterial approach and jugular vein access for the venous access. PHIL® 25% is chosen as the embolic agent.
While the case proceeds, the panelists discuss the advantages of each embolic agent – Onyx®, SQUID® or PHIL® – looking at which uses less reflux to advance, whether they all “laminate” in the same fashion as well as their relative viscosities or densities. The question of whether they be combined, such as using a “PHIL to make the plug and SQUID to flow” is discussed. Pacing and blood pressure, as well as heparin use, are discussed as well.
Meanwhile, anatomical challenges in navigating the draining vein make it impossible to access the AVM. Having achieved decent arterial access, the strategy changes, using the vein as a “contra pressure” to come back into the nidus, occluding the vein to reflux from the vein into the nidus.
This done, Prof. Moret and his team use the embolic device to isolate the AVM, but the debate rages back at LINNC: Are there other arteries to occlude? Should this patient have gone to surgery – and not embolisation?
What do you think? Join the discussion here…
This LIVE case corresponds to the highest ethical standards in medicine and is posted on LINNC Online for educational purposes only to allow medical professionals to improve their knowledge about these procedures and how to best treat their patients.
