Image-guided embolization of arteriovenous malformations of the hand using Ethylene-vinyl Alcohol Copolymer

Abstract

PURPOSE This study aimed to evaluate the safety and outcome of image-guided embolization for treating arteriovenous malformations (AVMs) of the hand using ethylene-vinyl alcohol copolymer (EVOH). METHODS A retrospective, multicenter cohort of 15 patients with AVMs of the hand treated with 35 imageguided embolotherapies using EVOH was investigated. Clinical history, symptomatology, and imaging findings were assessed to evaluate clinical outcome (symptom-free, partial relief of pain, no improvement of pain, and clinical progression despite embolization), lesion devascularization (total, 100%; near-total, 90%-99%; substantial, 70%-90%; partial, 30%-70%; and failure, 0%-30%), and peri- and postprocedural complication rates (major complications classified according to CIRSE guidelines). Substratification analysis was performed with respect to the involvement of different anatomical compartments and the injected volume of the embolic agent. RESULTS Patients were treated for pain (93.3%), skin ulceration (46.7%), and local bleeding (33.3%). The mean number of embolotherapies was 2.3 (±1.1) in 3 patients, a planned surgical resection was conducted after embolization. Clinical outcome after a median follow-up of 18 months revealed an overall response of 11/15 patients (73.3%). Imaging at last follow-up revealed 70%- 99% reduced vascularization in 12/15 patients (80%) including 2 patients (13.3%) with a neartotal devascularization of 90%-99%. Peri- and postprocedural complications occurred in 8.5% and 31.5%, respectively, including 17.1% major complications, in 1 case requiring a previously unplanned resection. Involvement of the finger was associated with increased rates of persistent symptoms compared to the other groups (P=.049). No significant difference between the embolic agent volume injected and complication rates was found (P=.372). CONCLUSION Image-guided embolization using EVOH-based liquid embolic agents is effective for treating AVMs of the hand in the mid-term.

Figure 1.

A 26-year-old female patient presenting with an AVM at the wrist of the right hand. (a) Clinical examination revealed peripheral ischemia with incipient local dystrophia of the surrounding soft tissue (arrow) and some superficially apparent vascular structures. (b) Negative roadmap images present the extent of the lesion predominantly involving dorsal wrist and carpal structures (arrow). (c, d) Periprocedural DSA via the transarterial route demonstrates multiple fine afferent arteries originating from the ulnar (arrow) and radial artery shunting to venous vascular structures. After 3 treatment sessions, the patient showed satisfying improvement of symptoms (Stage I, according to Schobinger classification) at terminal follow-up. AVM, arteriovenous malformation; DSA, digital subtraction angiography.

Figure 2.

A 42-year-old male patient presenting with an AVM at the middle and distal phalanx of the right fourth finger. After near-total devascularization of the malformation, previously planned partial amputation of the affected digit was performed. (a, b) Clinical examination prior to therapy revealed severe peripheral ischemia with consecutive local dystrophy and necrosis of the surrounding soft tissue (arrow), Stage III, according to Schobinger classification. (c) Periprocedural DSA image using transarterial route by means of which the lesion could not be adequately reached. (d) Periprocedural negative roadmap image demonstrates inserted angiocatheter (arrow) after change to the transvenous route. (e, f) Periprocedural DSA while AVM embolization using the transvenous approach (arrow). (g) X-ray after previously planned amputation of the distal and part of the middle phalanx shows the amputation socket at the affected digit (arrow) and residual, embolized vascular structures. (h) Coronal MR angiography revealed near-total devascularization of the residual AVM 2 years after completed amputation. (i) Axial T2-weighted MR image presents residual, embolized vascular structures 2 years after amputation (arrow). (j, k) Clinical presentation of the amputation socket (arrow) at terminal follow-up (2 years after completed interdisciplinary treatment), here the patient presented painless. MR, magnetic resonance.

Figure 3.

A 18-year-old female patient presenting with an AVM at the right distal palm as well as third and fourth finger. Six weeks after the fifth embolization session of the malformation, a secondary bacterial infection with consecutive onyx cast extrusion was observed. (a) At pre-treatment clinical examination the patient’s findings included signs of peripheral ischemia and local bleeding, Stage III, according to Schobinger classification. Initially, additive surgical resection was planned after sufficient devascularization. (b, c) Coronal MR angiography and periprocedural DSA image visualize the anatomical extension of the lesion at the distal carpal region and the two affected fingers of the right hand. (d) angiogram of draining veins following direct puncture of the main outflow vein, used for subsequent retrograde EVOH embolization (arrow). (e) EVOH cast after retrograde embolization (f, g) Clinical presentation of postprocedural late complication (6 weeks after the fifth embolization session) with secondary bacterial infection and consecutive extrusion of the onyx cast through the adjacent tissue (arrows). Subsequent attempted surgical onyx removal at the extrusion site was ineffective resulting in increased distal necroses. (h) Clinical presentation 2 months after the previously planned surgical resection (amputation of 2 fingers and part of the metacarpals) which could be performed successfully 5 months after the postprocedural late complication. Here, the patient presented with relief of pain. EVOH, ethylene-vinyl alcohol copolymer.