Background There are no reports that describe complete flow control using concurrent transient rapid ventricular pacing or intravenous (IV) adenosine and afferent arterial balloon flow arrest to aid transvenous embolization of cerebral arteriovenous malformations (AVM). We describe our experience with the use of this technique in patients undergoing transvenous AVM embolization.
Methods Consecutive patients in whom transvenous embolization was attempted at our institute between January 2017 and July 2019 were included. Anatomical AVM features, number of embolization stages, technique of concurrent transient rapid ventricular pacing and afferent arterial balloon flow arrest, complications, and clinical and radiological outcomes were recorded and tabulated.
Results Transvenous AVM embolization was attempted in 12 patients but abandoned in two patients for technical reasons. Complete embolization was achieved in 10 patients, five of whom had infratentorial AVMs. All 10 had a single primary draining vein. Rapid ventricular pacing was used in nine cases; IV adenosine injection was used in one case to achieve cardiac standstill. Complete AVM nidus obliteration was achieved with excellent neurologic outcome in nine cases, with transvenous embolization alone in two cases, and with staged transarterial followed by transvenous embolization in the others. Two patients developed hemorrhagic complications intraprocedurally. One patient was managed conservatively and the other operatively with AVM excision and hematoma evacuation; both made an excellent recovery without any neurologic deficits at 3 months.
Conclusion Complete flow control using concurrent transient rapid ventricular pacing with afferent arterial balloon flow arrest technique is safe and feasible for transvenous embolization of select AVMs.
- arteriovenous malformation
- liquid embolic material
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Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.
Contributors Conception and design: AHS, MW. Acquisition of the data: MW, HHR, FC. Analysis and interpretation of the data: all authors. Drafting the manuscript: MW. Critically revising the manuscript: all authors. Reviewing submitted version of the manuscript: all authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests KVS: Consulting and teaching for Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute; Co-Founder: Neurovascular Diagnostics, Inc. JMD: Research grant: National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo; Consulting: Medtronic; Honoraria: Neurotrauma Science, LLC; Shareholder/ownership interests: Cerebrotech, RIST Neurovascular. EIL: Shareholder/ownership interests: NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical; National Principal Investigator/Steering Committees: Medtronic (merged with Covidien Neurovascular) SWIFT Prime and SWIFT Direct Trials; Honoraria: Medtronic (training and lectures); Consultant: Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed; Advisory Board: Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical, Endostream Medical; Site Principal Investigator: CONFIDENCE study (MicroVention), STRATIS Study—Sub I (Medtronic). AHS: Financial interest/investor/stock options/ownership: Amnis Therapeutics, Apama Medical, Blink TBI Inc., Buffalo Technology Partners Inc., Cardinal Consultants, Cerebrotech Medical Systems, Inc., Cognition Medical, Endostream Medical Ltd, Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc., Q’Apel Medical Inc, Rebound Therapeutics Corp., Rist Neurovascular Inc., Serenity Medical Inc., Silk Road Medical, StimMed, Synchron, Three Rivers Medical Inc., Viseon Spine Inc.; Consultant/Advisory Board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd, Guidepoint Global Consulting, Imperative Care, Integra LifeSciences Corp., Medtronic, MicroVention, Northwest University–DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical Inc., Rapid Medical, Rebound Therapeutics Corp., Serenity Medical Inc., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates; Principal Investigator/steering comment of the following trials: Cerenovus NAPA and ARISE II; Medtronic SWIFT PRIME and SWIFT DIRECT; MicroVention FRED & CONFIDENCE; MUSC POSITIVE; and Penumbra 3D Separator, COMPASS, and INVEST.
Provenance and peer review Not commissioned; externally peer reviewed.