The evolution of endovascular treatment for intracranial arteriovenous malformations

Abstract

<jats:p>✓ Endovascular therapy for arteriovenous malformations (AVMs) remains a relatively new approach. Beginning in the 1960s with the use of flow-directed techniques for selective embolization, hemodynamic alterations have been used to treat these lesions. In every aspect of treatment, technological advances, including catheters, embolic materials, angiography suites, and pharmacological agents, have improved outcomes while lowering the risk to patients.</jats:p> <jats:p>In this article, the authors review the technical evolution of endovascular AVM therapy. Developments in embolic materials, beginning with foreign bodies and autografts and continuing through to highly engineered contemporary substances, are discussed. Finally, changes in treatment paradigms that have occurred over the years are traced. Within neurosurgery, this specialty has shown some of the fastest growth and development in recent decades. As minimally invasive approaches are embraced in all areas of medicine, it is clear that this treatment modality will continue to be refined.</jats:p>

Vascular inflammation with eosinophils after the use of n-butyl cyanoacrylate liquid embolic system

“…The use of cyanoacrylate derivatives for intra-arterial treatment of AVMs has proved beneficial both as an adjunct to surgery and as monotherapy 3 4. While these compounds are generally accepted as benign, it has been established through animal studies that many of them do have direct and or indirect cytotoxic effects and that they can induce inflammatory and immunological foreign body responses.…”

“…The advantages of preoperative embolization before staged open surgical resection are well proven 1 3. Benefits such as reduced operating time, decreased intraoperative blood loss, and reduced morbidity and mortality have been a driving force for the development of newer, safer, more effective materials and delivery systems for the intra-arterial embolization of AVMs 3 4. There are currently a number of different embolic agents with a wide variety of physical properties in use for the treatment of intracranial vascular malformations with the mainstays being cyanoacrylate adhesives, ethylene-vinyl alcohol copolymer (Onyx), and platinum coils 4…”

“…n-Butyl cyanoacrylate (n-BCA) is a widely used agent in interventional neuroradiology 4. It was initially developed in response to technical difficulties and safety concerns with its precursor, isobutyl-2-cyanoacrylate (i-BCA), and has since replaced i-BCA as the primary cyanoacrylate in use 4.…”

“…It was initially developed in response to technical difficulties and safety concerns with its precursor, isobutyl-2-cyanoacrylate (i-BCA), and has since replaced i-BCA as the primary cyanoacrylate in use 4. Several studies describe the local tissue response to n-BCA as generally benign with little tissue damage and cytotoxicity 5.…”

Pial non-galenic arteriovenous fistulas

“…Onyx has recently been used to treat intracranial AVFs [9,29,30,35,36], both alone and with coils. Although Onyx does not adhere to catheters, reflux must be minimized to prevent catheter entrapment and consequent hemorrhagic complications during catheter withdrawal.…”