J Cerebrovasc Endovasc Neurosurg.  2016 Jun;18(2):90-99. 10.7461/jcen.2016.18.2.90.

Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes

• Conger JR
• Ding D
• Raper DM
• Starke RM
• Durst CR
• Liu KC
• Jensen ME
• Evans AJ

• KMID: 2354882
• DOI: http://doi.org/10.7461/jcen.2016.18.2.90

Abstract

OBJECTIVE
Embolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs.
MATERIALS AND METHODS
We performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed.
RESULTS
A total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm³). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months).
CONCLUSION
Preoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.

Keyword

Endovascular procedures; Intracranial arteriovenous malformation; Intracranial hemorrhages; Microsurgery; Stroke; Vascular malformations

MeSH Terms

Cohort Studies
Demography
Endovascular Procedures
Follow-Up Studies
Hemorrhage
Humans
Intracranial Arteriovenous Malformations*
Intracranial Hemorrhages
Microsurgery
Mortality
Polyvinyl Alcohol
Retrospective Studies
Silk*
Stroke
Sutures*
Vascular Malformations
Polyvinyl Alcohol
Silk

Figure

• 

  Fig. 1 Cerebral angiography, (A) lateral and (B) AP views of a right internal carotid artery (ICA) injection, shows a 2.9×1.6×1.7 cm nidus in the posterior occipitotemporal region with a 7 mm intranidal aneurysm. The arterial supply is from the branches of the right middle cerebral artery (MCA) and posterior cerebral artery (PCA), through an enlarged fetal posterior communicating artery, and venous drainage is strictly superficial into the superior sagittal and right transverse sinuses. This Spetzler-Martin grade II arteriovenous malformation (AVM) was embolized through the right PCA branch feeding artery with 4-0 silk suture, 350-500 ?m polyvinyl alcohol particles, and a single 2×6 hydrocoil. The MCA branch feeder could not be safely embolized due to en passage supply to normal brain parenchyma. Post-embolization angiography, (C) lateral and (D) AP views of a right ICA injection, shows less than 25% AVM devascularization, but significantly reduced arterial supply from the embolized PCA branch. Postoperative angiography, (E) lateral and (F) AP views of a right ICA injection, performed six months after surgical resection, shows no evidence of residual nidus.

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