Peripheral Arteriovenous Malformations with a Dominant Outflow Vein: Results of Ethanol Embolization

OBJECTIVE: To assess retrospectively the treatment results of ethanol embolization of peripheral arteriovenous malformations (AVMs) with a dominant outflow vein (DOV). MATERIALS AND METHODS: Nineteen patients who had peripheral AVMs with a DOV were enrolled in this study (mean age, 29.7 years; range, 15-42 years). Fifty-one ethanol embolizations (mean, 2.7; range, 1-8) were performed by direct puncture (n = 29), the transarterial approach (n = 13), the transvenous approach (n = 5), or a combination of methods (n = 4) under general anesthesia. Coil and/or core-removed guide wire embolization of the DOV or another flow occlusion technique (i.e., use of an external pneumatic pressure cuff) to achieve vascular stasis were required in all patients during ethanol embolization. Clinical follow-up (mean, 22.2 months; range, 1-53 months) was performed for all patients, and imaging follow-up (mean, 22.1 months; range, 2-53 months) from the last treatment session was performed for 14 patients. The therapeutic outcome (cure, improvement, no change, or aggravation) was assessed according to the clinical response and the degree of devascularization at angiography. RESULTS: Ethanol embolization was considered as an effective procedure in all patients. Thirteen (68%) of 19 patients were cured and six displayed improvement. Three of six patients with improvement needed further treatment sessions for residual AVMs. Four patients (21%) experienced a total of eight complications. Five complications (three events of a distal embolism and one event each of a urinary bladder necrosis and a brain infarct related to the accidental cannulation of the common carotid artery during insertion of the Swan-Ganz catheter) were major and three complications (skin necrosis) were minor. CONCLUSION: Peripheral AVMs with a DOV can be effectively treated with a high cure rate by the use of ethanol embolization alone or in conjunction with the use of coil and/or core-removed guide wire embolization.

Carbon Dioxide Digital Subtraction Angiography in Percutaneous Sclerotherapy of Venous Hemangiomas

PURPOSE: To investigate the usefulness of carbon dioxide digital subtraction angiography (CO2-DSA) in direct puncture sclerotherapy of venous hemangiomas involving extremities. MATERIALS AND METHODS: Direct puncture sclerotherapy was performed in 12 patients with venous hemangioma of extremities. After direct puncture of the hemangiomas, 30-50 cc of CO2 was manually injected and digital subtraction angiograms were obtained. If draining vein was visualized, a tourniquet was applied at the proximal site to compress the draining veins. There after, radiopaque embolic materials such as 1:3 mixture of Lipiodol and absolute ethanol or ethanolamineoleate-Lipiodol-Avitene (microfibrillar collagen hemostat) mixture were slowly injected under the fluoroscopic guidance. RESULTS: Rapid injection of large amount of a CO2 enabled the visualization of wide areas of venous hemangiomas in 11 patients. Draining veins were reliably demonstrated in 10 patients and pulmonary embolism of embolic materials was effectively prevented by proximal tourniquet application. Because of radiolucent nature of CO2 retained in hemangiomas, we could clearly identify the distribution of radiopaque embolic materials under fluoroscopy. Retained CO2 also could be used as a guide for additional multiple puncture of hemangiomas. There was no systemic symptoms or complications related to CO2-DSA. CONCLUSION: CO2-DSA is a convenient, safe and useful angiographic technique in direct puncture sclerotherapy of hemangiomas involving extremities.