Embolization of Brain Arteriovenous Malformations for Cure: Because We Could or Because We Should?

Jayaraman, Mahesh; Cloft, Harry J.

doi:10.3174/ajnr.a1394

Cited by 23 publications

(8 citation statements)

References 11 publications

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“…It is well documented, however, that a subset of AVMs can be angiographically occluded using embolization. Whether curative embolization should be considered a reliable primary treatment, equivalent to microsurgery and radiosurgery, remains controversial 7,24 and is dependent upon 3 factors: 1) is there a subset of AVMs that can be predictably cured with embolization; 2) can embolization be performed with minimal morbidity; and 3) is it a durable treatment?…”

mentioning

confidence: 99%

Curing arteriovenous malformations using embolization

Potts

Zumofen

Raz

et al. 2014

FOC

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Endovascular embolization is typically reserved as an adjuvant therapy in the management of cerebral arteriovenous malformations (AVMs), either for preoperative devascularization or preradiosurgical volume reduction. Curative embolization plays a limited role in AVM treatment but several studies have shown that it is possible, especially with later-generation liquid embolic agents. Given the complexity of AVM anatomy and the recent controversies over the role of any intervention in AVM management, it is critical that the cerebrovascular community better define the indications of each treatment modality to provide quality AVM management. In this review, the authors evaluate the role of curative AVM embolization. Important considerations in the feasibility of curative AVM embolization include whether it can be performed reliably and safely, and whether it is a durable cure. Studies over the past 20 years have begun to define the anatomical factors that are amenable to complete endovascular occlusion, including size, feeding artery anatomy, AVM morphology, and endovascular accessibility. More recent studies have shown that highly selected patients with AVMs can be treated with curative intent, leading to occlusion rates as high as 100% of such prospectively identified lesions with minimal morbidity. Advances in endovascular technology and techniques that support the efficacy and safety of curative embolization are discussed, as is the importance of superselective diagnostic angiography. Finally, the durability of curative embolization is analyzed. Overall, while still unproven, endovascular embolization has the potential to be a safe, effective, and durable curative treatment for select AVMs, broadening the armamentarium with which one can treat this disease.

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confidence: 99%

Curing arteriovenous malformations using embolization

Potts

Zumofen

Raz

et al. 2014

FOC

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“…Whereas cure of dural arteriovenous fistulae is reported in most of the treated patients with no major periprocedural morbidity, the treatment of brain arteriovenous malformation remains challenging. [71][72][73] The goal to cure brain arteriovenous malformation with use of Onyx is achieved in 2% to 28% of the patients with permanent morbidity and mortality of 3% to 11%. Whereas increased cure rates are achieved, the periprocedural complications are higher as compared with other liquid embolic agents used in the past.…”

Section: Brain Arteriovenous Malformation and Dural Arteriovenous Fismentioning

confidence: 99%

“…Whereas increased cure rates are achieved, the periprocedural complications are higher as compared with other liquid embolic agents used in the past. 73,74 The ARUBA Study has started randomizing patients with unruptured brain arteriovenous malformations between conservative management and active intervention, which can include interventional radiology. The results will be of major importance, but will not be available for several years.…”

Section: Brain Arteriovenous Malformation and Dural Arteriovenous Fismentioning

confidence: 99%

Advances in Interventional Neuroradiology

Wakhloo

DeLeo

Brown

2009

Stroke

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Abstract-In 2008 we witnessed a rapid advancement in stent technology, which is reflected in the high number of case reports, publications of case series, and randomized trials. Stents not only served for a combined intrasaccular and extrasaccular treatment of challenging aneurysms but also assisted the revascularization in acute and chronic ischemic conditions of the neurovascular system. Although a self-expanding nitinol semiopen cell stent is currently used for intracranial occlusive disease, a new retrievable closed-cell designed stent is widely used for aneurysms because of its easy delivery through a microcatheter in frequently tortuous head and neck as well as cerebrovascular circulation (Figure 1 6 The study evaluated carotid artery stenting (CAS) with the use of an emboli-protection device and compared it to carotid endarterectomy (CEA) in 334 patients at increased risk for complications from CEA who had either Ն50% symptomatic carotid artery stenosis or an asymptomatic stenosis of Ն80%. Follow-up data were available for 260 patients, 85.6% in CAS arm, and 70.1% in CEA arm. The prespecified major secondary end point at 3 years was a composite of death, stroke, or MI within 30 days after the procedure, or death or ipsilateral stroke between 31 days and 3 years. The prespecified major secondary end point occurred in 41 patients in the CAS group (cumulative incidence, 24.6%; Kaplan-Meier estimate, 26.2%) and 45 patients in CEA group (cumulative incidence, 26.9%; Kaplan-Meier estimate, 30.3%; absolute difference in cumulative incidence for CAS group, Ϫ2.3%; 95% CI, Ϫ11.8 -7.0). There were 15 strokes in each of the 2 arms, a rate of 9% over 3 years in each group, of which 11 in CAS group and 9 in CEA group were ipsilateral. The authors concluded that no significant difference could be found in outcome between both groups. 6 It is important to be aware of the fact that the majority of patients in SAPPHIRE were asymptomatic and both the CEA and CAS groups had a similar 30-day rate of stroke at 3 years at 9% to that recorded in the trials of CEA for asymptomatic patients in the medically treated patients (Ϸ8%). Unfortunately, SAPPHIRE did not report data for symptomatic and asymptomatic patients separately. Moreover, follow-up data were only available at 3 years for 86% of the CAS group and 70% of the CEA group. The conclusions that can be drawn from the SAPPHIRE report are therefore limited.The multicenter, single-arm BEACH, a nonrandomized CAS study with emboli-protection device for high-risk surgical patients, enrolled 480 patients with CAS. 7 The primary end point (all stroke, death, or Q-wave MI through 30 days; non-Q-wave MI through 24 hours; and ipsilateral stroke or neurological death through 1 year) was compared with a proportionally weighted objective performance criterion of 12.6% for published CEA results in similar patients, plus a prespecified noninferiority margin of 4%. At 1 year, the composite primary end point occurred in 8.9%, with a repeat revascularization rate of 4.7% (upper 95% confidence...

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“…In experienced hands, an increased cure rate may be attainable, but the complication rate remains comparable to that of formerly used liquid embolic agents (11,12).…”

mentioning

confidence: 80%

Endovascular Treatment of Dural Carotid Cavernous Sinus Fistulas

Wakhloo¹

2009

Journal of Neuro-Ophthalmology

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Embolization of Brain Arteriovenous Malformations for Cure: Because We Could or Because We Should?

Cited by 23 publications

References 11 publications

Curing arteriovenous malformations using embolization

Curing arteriovenous malformations using embolization

Advances in Interventional Neuroradiology

Endovascular Treatment of Dural Carotid Cavernous Sinus Fistulas

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