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• W2221865624 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. 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. Peripheral arteriovenous malformations (AVMs) remain most challenging among the various congenital vascular malformations to be treated.1Lee B.B. Baumgartner I. Berlien H.P. Bianchini G. Burrows P. Do Y.S. et al.Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management.Int Angiol. 2013; 32: 9-36PubMed Google Scholar Minimally invasive embolization techniques are the preferred therapeutic option.2Cho S.K. Do Y.S. Kim D.I. Kim Y.W. Shin S.W. Park K.B. et al.Peripheral arteriovenous malformations with a dominant outflow vein: results of ethanol embolization.Korean J Radiol. 2008; 9: 258-267Crossref PubMed Scopus (45) Google Scholar, 3Burrows P.E. Vascular malformations involving the female pelvis.Semin Intervent Radiol. 2008; 25: 347-360Crossref PubMed Scopus (34) Google Scholar, 4Numan F. Omeroglu A. Kara B. Cantasdemir M. Adaletli I. Kantarci F. Embolization of peripheral vascular malformations with ethylene vinyl alcohol copolymer (Onyx).J Vasc Interv Radiol. 2004; 15: 939-946Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Arteriographic studies determining the angioarchitecture are helpful to determine the specific endovascular form of treatment. Various arteriographic classification systems have been proposed.5Houdart E. Gobin Y.P. Casasco A. Aymard A. Herbreteau D. Merland J.J. A proposed angiographic classification of intracranial arteriovenous fistulae and malformations.Neuroradiology. 1993; 35: 381-385Crossref PubMed Scopus (139) Google Scholar, 6Do Y.S. Park K.B. Cho S.K. How do we treat arteriovenous malformations (tips and tricks)?.Tech Vasc Interv Radiol. 2007; 10: 291-298Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar The Yakes AVM classification system advanced the descriptions of AVM angioarchitectures, building on previously published classification systems.7Baumgartner I. Yakes W.F. Interventional treatment of arterio-venous malformations.Gefässchirurgie. 2014; 19: 325-330Crossref Scopus (30) Google Scholar The Yakes type I AVM (direct artery-to-vein connection) and type IV AVM (network of innumerable AV shunts without a defined nidus infiltrating tissues with capillary beds interspersed among the innumerable AV shunts) were added. Furthermore, refinement has led to more specific endovascular treatment strategies related to Yakes types II, IIIa, and IIIb AVMs.7Baumgartner I. Yakes W.F. Interventional treatment of arterio-venous malformations.Gefässchirurgie. 2014; 19: 325-330Crossref Scopus (30) Google Scholar, 8Yakes W.F. Yakes A.M. The Yakes AVM classification system: therapeutic implications.in: Mattassi R. Loose D.A. Vaghi M. Atlas of hemagiomas and vascular malformations. 2nd edition. Springer Italia, Milan2015: 263-276Abstract Full Text Full Text PDF Google Scholar The goal of any AVM embolization is to eliminate the AVM nidus.9Doppman J.L. The nidus concept of spinal cord arteriovenous malformations. A surgical recommendation based upon angiographic observations.Br J Radiol. 1971; 44: 758-763Crossref PubMed Scopus (43) Google Scholar A combination of approaches to deliver embolic agents using transarterial, direct puncture, or retrograde transvenous embolization may be required. Coils can lessen endovascular complications when densely packed in the aneurysmal vein of Yakes type IIIa and type IIIb AVMs. Ethanol additionally may be required to completely occlude the coiled aneurysmal vein. Occlusion of arterial feeders may temporarily shrink the AVM, but it will invariably recur.10Doppman J.L. Pevsner P. Embolization of arteriovenous malformations by direct percutaneous puncture.AJR Am J Roentgenol. 1983; 140: 773-778Crossref PubMed Scopus (54) Google Scholar We present three illustrative patients with Yakes type IIIb and type IV AVMs at the plantar aspect of the foot who were successfully treated by endovascular techniques. All patients gave written informed consent for publication. A 37-year-old man was referred with pain in his right foot with walking. The patient had undergone several intra-arterial embolization procedures 6 years earlier. After embolization of branches of the tibial arteries using ethylene vinyl alcohol (Onyx; ev3 Endovascular Inc, Plymouth, Minn) and n-butyl cyanoacrylate (Histoacryl; TissueSeal, LLC, Ann Arbor, Mich), a large area of plantar necrosis developed (Fig 1, A and B). Arteriography confirmed recurrent AVM with numerous small-sized collaterals (Yakes type IIIb; Fig 1, C). The AVM showed an aneurysmal out-flow vein enlargement and multiple draining outflow veins. A 4F Glidecath (Terumo Medical Corp, Somerset, NJ) was positioned in the distal posterior tibial artery for arteriographic guidance. The aneurysmal vein was punctured with an 18-gauge/15-cm Chiba Biopsy Needle (Cook Medical, Bloomington, Ind) using fluoroscopic guidance. Coiling of the aneurysmal vein was performed with eight fibered coils of 0.035-inch size, 6-mm diameter and three fibered coils of 0.035-inch size, 4-mm diameter (Nester Embolization Coil; Cook Medical). Injection of 4.5 mL of 96% ethanol completed occlusion of the vein aneurysm (Fig 1, D). At the 1-year arteriographic follow-up, a small residual asymptomatic second AVM compartment was noted (Fig 1, E). A 44-year-old man with an AVM on the plantar aspect of the right foot was referred due to constant pain for almost 1 year (Fig 2, A). As described in patient 1, the vein aneurysm was percutaneously coiled using five fibered coils of 0.018-inch size, 10-mm diameter, and four fibered coils of 0.018-inch size, 8-mm diameter (Nester Embolization Coils) and subsequently embolized with 25 mL of 96% ethanol via the same needle used for coiling (Fig 2, B and C). Use of a wart-removing cream resulted in erosion of one coil through the skin, which was removed with a small surgical incision 3 months after embolization (Fig 2, D). At 12 months, complete occlusion of the AVM was observed by Doppler ultrasound imaging, with normalized, triphasic waveforms of the common femoral and tibial arteries. A 19-year-old woman with an AVM of the left foot plantar aspect suffered from progressive pain. AVM was verified by Duplex ultrasound imaging, magnetic resonance imaging, and catheter arteriography (Fig 3, A). Direct puncture of the Yakes type IIIb AVM vein aneurysms was performed (Fig 3, B). Three fibered coils of 0.035-inch size, 6-mm diameter, and six fibered coils of 0.035-inch size, 10-mm diameter (Nester Embolization Coils) were placed, and 6 mL of 96% ethanol was injected. Four weeks later, another treatment was performed in a staged fashion, and 4 coils of 0.018-inch size, 3-mm diameter, 2 coils of 0.018-inch size, 4-mm diameter (detachable Azure Coils, Terumo), 3 coils of 0.018-inch size, 2.5-mm diameter, and 10 coils of 0.018-inch size, 2-mm diameter (Vortex Coils; Boston Scientific, Marlborough, Mass) were placed. Then, 10.5 mL of ethanol was injected to totally occlude the AVM. With complete occlusion of the dominant aneurysmal out-flow vein of the Yakes type IIIb AVM, an adjacent additional infiltrative Yakes Type IV AVM became obvious (Fig 3, C). During direct puncture repair with 23-gauge needles, 6.9 mL of ethanol was inject into areas of the infiltrative Yakes type IV AVM. Residual areas were repetitively treated with injections of 11.5 mL and 12.4 mL ethanol 4 and 9 weeks later. Direct puncture injections in the AVM microfistulas allowed undiluted ethanol embolization. When a feeding arterial pedicle was punctured that flowed into tissue and the Yakes type IV AVM, then a 50%-50% mixture of ethanol and nonionic contrast was injected (Fig 3, D). Arteriography showed complete occlusion of the Yakes type IIIb AVM and nearly complete disappearance of the Yakes type IV AVM component (Fig 3, E), with absence of symptoms at 6 months of follow-up. These cases demonstrate the value of the Yakes AVM classification that directs the type of endovascular treatment plan of type IIIb and type IV AVMs. According to experience, recurrence is rare, with no flow at 6 to 12 months of follow-up. The first case illustrates that proximal occlusion of the feeding arterial supply will never effectively treat an AVM. Proliferation of innumerable new feeding vessels via angiogenesis stimulation is a serious problem, which routinely worsens the clinical situation. Direct percutaneous puncture or retrograde catheter vein approaches with coiling of the vein outflow aneurysm can be very often be a definitive treatment. Through the 18-gauge lumen, coils (fibered and nonfibered) with diameter sizes of 0.035 and 0.038 inches can be easily placed into the target area. Size and length of the coils depend on anatomy and availability of coils. At times, if the vein aneurysm is incompletely coiled, ethanol can be injected to reflux into the many microfistulas in the vein wall (nidus). After dense coiling of the venous outflow aneurysm, very little if any additional ethanol is often needed to completely block blood flow. Several AVM types can coexist. As illustrated in patient 3, once the Yakes type IIIb AVM was obliterated, the residual type IV infiltrative AVM could be appreciated. The type IV AVM requires a different treatment strategy than the type IIIa and IIIb AVMs, as illustrated. Complication rates with any embolic agent in AVM treatment are an issue that should be minimized. Reports range between 10% and 30%, with tissue necrosis and neuropathy being the complications most often seen.11Lee K.B. Kim D.I. Oh S.K. Do Y.S. Kim K.H. Kim Y.W. Incidence of soft tissue injury and neuropathy after embolo/sclerotherapy for congenital vascular malformation.J Vasc Surg. 2008; 48: 1286-1291Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Safe use of ethanol in AVM embolization requires accurate delivery by precise placement solely in the AVM nidus vasculature that is non-nutritive (ie, sparing all capillary beds). An injection of ethanol into a feeding artery that is too proximal will cause severe tissue necrosis by thrombosing and destroying nutritive capillary beds proximal to the AVM.11Lee K.B. Kim D.I. Oh S.K. Do Y.S. Kim K.H. Kim Y.W. Incidence of soft tissue injury and neuropathy after embolo/sclerotherapy for congenital vascular malformation.J Vasc Surg. 2008; 48: 1286-1291Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 12Yakes W.F. Luethke J.M. Merland J.J. Rak K.M. Slater D.D. Hollis H.W. et al.Ethanol embolization of arteriovenous fistulas: a primary mode of therapy.J Vasc Interv Radiol. 1990; 1: 89-96Abstract Full Text PDF PubMed Scopus (73) Google Scholar, 13Yakes W.F. Pevsner P. Reed M. Donohue H.J. Ghaed N. Serial embolizations of anextremity arteriovenous malformation with alcohol via direct percutaneous puncture.AJR Am J Roentgenol. 1986; 146: 1038-1040Crossref PubMed Scopus (86) Google Scholar, 14Yakes W.F. Endovascular management of high-flow arteriovenous malformations.Semin Intervent Radiol. 2004; 21: 49-58Crossref PubMed Scopus (46) Google Scholar, 15Vogelzang R.L. Atassi R. Vouche M. Resnick S. Salem R. Ethanol embolotherapy of vascular malformations: clinical outcomes at a single center.J Vasc Interv Radiol. 2014; 25: 206-213Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 16Ellman B.A. Parkhill B.J. Marcus P.B. Curry T.S. Peters P.C. Renal ablation with absolute ethanol: mechanism of action.Invest Radiol. 1984; 19: 416-423Crossref PubMed Scopus (49) Google Scholar, 17Türkbey B. Peynircioğlu B. Arat A. Canyiğit M. Ozer C. Vargel I. et al.Percutaneous management of peripheral vascular malformations: a single center experience.Diagn Interv Radiol. 2011; 17: 363-367PubMed Google Scholar Percutaneous biopsies with computed tomography guidance have demonstrated that 21-gauge and 18-gauge biopsy needles have low complication rates of 0.1% to 1.1%.18Welker J.A. Henshaw R.M. Jelinek J. Schmookler B.M. Malawer M.M. The percutaneous needle biopsy is safe and recommended in the diagnosis of musculoskeletal masses.Cancer. 2000; 89: 2677-2686Crossref PubMed Scopus (141) Google Scholar, 19Livraghi T. Damascelli B. Lombardi C. Spagnoli I. Risk in fine-needle abdominal biopsy.J Clin Ultrasound. 1983; 11: 77-81Crossref PubMed Scopus (186) Google Scholar The new modified Yakes AVM classification system, particularly by directing specific therapeutic procedures of the specific AVM types defined by their angioarchitecture, is helpful in decision making and lowering complications. Coils can be curative, effectively packing the vein aneurysm outflow in Yakes type IIIa AVMs. Yakes type IIIb AVMs are more challenging because of the numerous draining veins emanating from the vein aneurysm, which may additionally need to be occluded and packed densely with coils. Yakes type IV AVMs consist of multiple arterioles flowing into numerous microfistulae that diffusely infiltrate the affected tissue. Therapy consists of injecting superselectively the in-flow artery to the AVFs with a 50%-50% mixture of ethanol and nonionic contrast, or direct puncture of the AVF and injecting pure ethanol, all of which can be curative in this specific AVM Type." @default.
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• W2221865624 title "Percutaneous embolization of arteriovenous malformations at the plantar aspect of the foot" @default.
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