Evolution of transvenous embolization in vein of Galen malformation: case series and review of the literature

Abstract

BackgroundTreatment of vein of Galen malformations (VOGMs) has improved greatly since the inception of endovascular treatment. Transvenous embolization (TVE) is an attractive option to achieve complete obliteration.ObjectiveTo review the literature on TVE of VOGM and then analyze our practice’s unique experience and evolving treatment strategies over 30 years.MethodsA retrospective review of our clinical database for patients with the diagnosis of VOGM treated between January 2004 and August 2021 was performed. A literature review of 49 relevant articles was also carried out.ResultsTVE in VOGM has evolved with initial introduction as a transtorcular (TT) approach, which then lost favor to transarterial embolization (TAE). TAE has been considered the more favorable approach in most high-volume centers. In more recent times, the transvenous embolization (TVE) approach has been revisited as a last treatment to achieve a cure after a series of TAE treatments. We presently favor beginning treatment with staged TAE to reduce flow to the lesion and, importantly, shrink the draining vein. This then allows for the performance of TVE with the Chapot pressure cooker technique (CPCT) with coils and liquid embolic embolization.ConclusionsTT TVE itself carries a high degree of risk and is most highly associated with long-term morbidities and mortality. Traditional transfemoral/transjugular TVE approaches are safe and effective in simple fistulas with a small venous pouch; however, we believe that the CPCT is the safest technique as a last-stage treatment for its security in avoiding reflux and obtaining occlusion of the small perforators.

Rapid ventricular overdrive pacing and other advanced flow-control techniques for the endovascular embolization of vein of galen malformations

“…In practice however, coil elongation into the flow stream of the shunt often precludes stable anchoring of the coil. More advanced techniques include the concurrent utilization of transarterial and transvenous embolization (9)(10)(11)(12)(13), the use of micro-balloon catheters to suppress arterial flow (14, 15), pharmacologically induced circulatory arrest via cardiac pause (16)(17)(18), and right ventricular overdrive pacing (19)(20)(21). Each technique has advantages and disadvantages and should be employed on a case-dependent basis after careful consideration of specific clinical, anatomical and hemodynamic factors.…”

“…Herein, we present these various techniques and review the available data on their utilization. Primary transvenous embolization of VOGM has largely fallen out of favor due to the high risk of hemorrhagic stroke resulting from occlusion of normal thalamostriate venous drainage (1,3,(6)(7)(8)(9). Nonetheless, adjunctive transvenous embolization approaches often play an important role in mitigating venous escape during VOGM embolization (9).…”

“…Primary transvenous embolization of VOGM has largely fallen out of favor due to the high risk of hemorrhagic stroke resulting from occlusion of normal thalamostriate venous drainage (1,3,(6)(7)(8)(9). Nonetheless, adjunctive transvenous embolization approaches often play an important role in mitigating venous escape during VOGM embolization (9). Some authors have reported partial, non-occlusive coiling of the aneurysmal median prosencephalic vein to "jail" the ostia of choroidal venous tributaries, thus establishing a barrier to prevent venous escape of coils and liquid embolics.…”

“…Additionally, some authors have reported that the interaction of high-flow jets with the intravascular “strainer effect” of the non-occlusive coil matrix can promote hemolysis and disseminated intravascular coagulation ( 22 , 23 ).To enhance the safety and efficacy of embolization, two transvenous techniques have been developed. These are the “ Brassel kissing microcatheter technique ” ( 3 , 9 , 11 ) and the “ Adapted Chapot pressure cooker technique ” ( 9 , 13 ).…”

Response to "Evolution of transvenous embolization in vein of Galen malformation: case series and review of the literature": to be or not to be

“…We read with interest the article by Fifi et al 1. They described their experience with the use of transvenous embolization (TVE) for residual vein of Galen malformation (VOGM) in patients who were treated previously with multiple rounds of transarterial embolization (TAE).…”