Peripheral Arteriovenous Malformations: Classification and Endovascular Treatment

Kenrick Lam, MD; Anil Pillai, MD; Mark Reddick, MD

Appl Radiol. 2017;46(5):15-21.

Abstract and Introduction

Introduction

In this review we cover the classification and endovascular management of arteriovenous malformations (AVMs). We begin by viewing AVMs in relation to the broader class of congenital vascular malformations and subsequently go into more depth on the clinical and pathologic characteristics that define AVMs. We then focus on the endovascular treatment options for peripheral AVMs and summarize the functional characteristics of the sclerosants and embolic agents available to clinicians today.

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Next Section

Abstract and Introduction
Vascular Malformations and Their Classification
Clinical Staging
Imaging Findings in AVMs
Endovascular Treatment Options
Treatment Techniques
Outcomes
Conclusion
References

Table 1. 2014 ISSVA Classification of Vascular Malformations
Simple	Capillary, Venous, Lymphatic, Arteriovenous, Arteriovenous Fistula
Combined	Any combination of simple malformations (eg. Capillary – Venous, Venous – Lymphatic, Capillary – Lymphatic – Venous)
Involves Major Vessels (Truncular)	Vessel Involved (Artery, Vein or Lymphatic) Anomaly of: Origin, Course, Number, Length, Diameter, Valves, Communication, Persistence (embryonal)
Part of Clinical Syndrome	Klippel-Trenaunay, Parkes Weber, Servelle-Martorell, Sturge-Weber, Mafucci, Cloves, Proteus, Bannayan-Riley

Simple malformations involve one type of vessel including vessel shunts such as AVMs. There are no longer arterial malformations. The star (*) indicates high-flow lesions. Combined malformations are any combination of simple malformations and can involve more than two different types. Truncular malformations are distinguished by the name of the vessel involved as well its anomalous characteristics. Clinical syndromes have a typical set of malformations that accompany them; thus, they are considered a single clinical entity.

Table 2. Schobinger Clinical Grading System of Arteriovenous Malformations
Stage 1	Warm, pink-blue stain
Stage 2	Stage 1 + Enlargement, pulsatile, bruit, thrill
Stage 3	Stage 2 + Ulceration, bleeding, pain, necrosis
Stage 4	Stage 3 + Heart failure

Table 3. Selected review of results of AVM embolization in various clinical situations and regions of the body.
Author	Patients	Embolic (patients)	Response (patients)	Complications (number of patients)
Acute Bleeding
Churojana, 2012³⁸	5	NBCA (33 - 50%)	Recurrence (3)	Infection (2)
McGrath, 2012²⁵	9	PVA (355 - 500 um, 150 - 250 um)	Requiring second embolization for control (1)	None
Pre-surgical
Pompa, 2011³⁹	11	PVA (7), Coils (4)	> 90% Flow reduction in 7 cases	None Reported
Lee, 2004⁴⁰	16	NBCA (13), Ethanol (3)	Cure (16)	Pulmonary Embolism (1)
Head and Neck
Kim, 2015 ⁴¹	45	Ethanol, NBCA (15), Onyx (1)	No response (3), Cure (8), Recurrence (5)	Skin necrosis (18 - 3 require grafting), bullae (12), Stroke (1), swelling requiring decompression (1)
Dmytriw, 2014³²	89 (244 sessions)	PVA (96), NBCA (103), Coils (5)	Cure (52 - 28 w/combined surgery, mostly small AVMs), Recurrence (2)	Swelling requiring intubation (1), post-operative bleeding (5), vision loss (1), stroke (1)
Pekkola, 2013¹³	19	Ethanol	6 with residual symptoms, 1 recurrence, 1 progression of symptoms	Skin necrosis (5 - 2 with secondary infection, 1 requiring surgery), mucosal necrosis (2), tissue necrosis (2), transient paresthesia (1), blindness (1)
Srinivasan, 2014²³	7	Onyx 18	Partial response	Skin necrosis (1), ankle stiffness (1),
Trunk, Pelvis, Extremities
Wohlgemuth, 2015³⁴	11	Onyx, Coils (4)	Cure (8), Partial (3), Recurrence (1)	No complications
Tan, 2004⁴²	13	NBCA (11), PVA (5, 300 - 500um)	No response (4), Cure (2), Recurrence (2)	Fracture (1), transient paralysis (1)
Cho, 2006³⁰	66	Ethanol	Cure (21), No relief (17)	Skin necrosis (31), bullae (10), paresthesias (2), stroke (1), embolism (3), permanent nerve injury (2), infection (2), tissue necrosis (1)
Rockman, 2003⁴³	50 (30 avm)	PVA (11) NBCA (22), ibca (6), coils (1)	Unchanged (4), Cured (14)	hematoma (1), recurrence requiring amputation (1)
Yakes, 2010⁴⁴	48	Ethanol, coils	Cured (36)	Transient nerve (4), blistering (4), PE (1), tissue necrosis requiring bowel diversion (1)
Pulmonary
Mager, 2004²⁹	112	Coils	Recanalization (19)	TIA (3), cerebral abscess (2), coil migration (5 - 3 requiring retrieval), pulmonary infiltrate (1), angina (1), DVT (1)
Letourneau, 2010⁴⁵	24	Vascular Plug	Recanalization (2 - of 19 pt f/u), all had sx improvement	No complications
Renal
Murata, 2014⁴⁶	12	Coils, NBCA (3), Gel Sponge (1), Ethanol (3)	Recurrence (2 - treated with coils only), Cure (10)	No complications
Dominant Outflow Vein Architecture
Conway, 2015¹⁹	14	Plug and coils (13), Ethanol (2), NBCA (11 - 1:1)	No response (1), Cure (5)	No complications
Sung, 2008³¹	19	Ethanol, coil (13)	Cure (13)	Embolism (3), stroke (1), bladder necrosis (1), skin necrosis (3)