Glubran 2: AVM

Ezio Lanza MD

We are now going to look at some case reports concerning the use of Glubran®2 in Arteriovenous and Venous Malformation, a wide area that Park and Young, among others, have successfully managed to classify in a chapter of their book “Congenital Vascular Malformations: A Comprehensive Review of Current Management”.

Park, Kwang & Do, Young. (2017). Angiographic Classification: Arteriovenous Malformation and Venous Malformation

The need for a systematic classification arises from the notion that different AVM types behave differently in terms of response, thus attempts have been made to standardize treatment according to AVM type.

CASE 1 – RHINOPHARYNX AVM

24 yo man – 1:4 ratio, 0.2ml boluses

A very young man with a small, oval-shaped malformation of the rhinopharynx located right behind the ethmoid bone, which rendered it inoperable. We saw we could gain direct access through the external carotid artery, performed a selective angiography, and then proceeded to distally place a micro-catheter and injected 0.2 ml of standard glue mixture, thus achieving full exclusion. As these kind of malformations are mostly congenital and do not tend to grow much over time, the successful result was confirmed at 2-years follow up.

CASE 2 – RIGHT THORACIC WALL AVM

28 yo man – multiple treatments

Such a large AVM usually requires multiple treatments: we started with selective catheterization of a malformed vessel arising directly from the right subclavian artery and made multiple attempts at using a high-density glue mixture to embolize different parts of the malformation. In these cases, surgery would be very invasive and the AVM would just grow back, so liquid embolic agents are our only option. The goal is to reduce the symptoms, do as little harm as possible, and go back at a later time when symptoms resurface. In our case, we treated the patient again after one year.

CASE 3 – LEFT THORACIC WALL

60 yo man

This is a very interesting case that goes to show how things do not always go as planned. The patient had a very symptomatic AVM with high-risk bleeding that was also eroding part of the bone cortex. A previous embolization with coils had produced no significant results. We performed an angiography of the left intercostal artery and used selective catheterization to enter the sac, then glued distally, creating a blockage. We kept injecting glue until there was a very low residual flow from the malformation. As shown in the bottom left picture, the result was very satisfactory, however, we later discovered that some glue had migrated to a spinal artery, thus provoking ischemia of the spinal cord. Luckily, using the small bolus technique meant that only a reduced amount of glue had migrated, and the damage was not severe. At follow up, a month ago, the patient exhibited only mild symptoms.

CASE 4 – GLUTEAL AVM

Another large AVM that we treated with coils first, then with glue. Because such cases need to be treated repeatedly, communication with the patient becomes very important: we create a relationship and monitor symptoms regularly so that we decide together with the patient when it is time to intervene again.

CASE 5 -PELVIC CHO TYPE 2 AVM

54 yo man – Large venous outflow 1:4 Glubran + Amplatzer plug

In this case, we needed to block the outflow from a large venous sac, so we used triple access (one arterial and two venous), placing a 32 mm Amplatzer plug on the large venous outflow of the AVM, This way we could operate with no risk of non-target embolization. We injected small amounts of glue, some of which gathered in high-density concentration just below the plug, which effectively stopped it from migrating into the pulmonary circulation system. This is also called the “Pressure Cooker Technique” , which can be used with liquid embolic agents. As the bottom picture shows, the final result was excellent. severe. At follow up, a month ago, the patient exhibited only mild symptoms.

CASE 6 – FOREFOOT AVM

Woman (35) – 0.1 ml Glubran®2 1:3 in the posterior tibial. Manual compression of the digital arteries

This was a wide AVM, similar to a sponge, which we embolized with a very dense mixture through a distally placed catheter while applying manual compression to the digital arteries. As you can see in the picture, digital circulation has been preserved. The result was satisfactory even though we noticed that a small part of the malformation appeared still vascularized. In treating AVMs, in fact, it is important to focus on the symptoms rather than on the image: striving for perfection will likely lead to nontarget embolization and its consequences.

CASE 7 – EMERGENCY EMBOLIZATION LARGE FACIAL AVM BLEEDING

This is a case of large AVM arising from the external carotid artery, which was bleeding into the mouth and therefore required emergency treatment. Nontarget embolization occurred, with some glue migrating to the internal carotid artery and displacing into the brain, provoking stroke-like symptoms. Thanks again to the sandwich technique and the glue having been injected in small boluses, the symptoms disappeared within a week. And at 3-months follow up, the signs of the non-target embolization had disappeared.

For those of you wishing to learn from our mistakes, we have published an open-access full report on this case, under the following title: “Full recovery after non-target cerebral embolization.”

Lanza E, Gennaro N, Poretti D, et al. Full recovery after non-target cerebral embolization of n-butyl-cyanoacrylate occurred during emergency treatment of a facial arteriovenous malformation. CVIR Endovasc. 2019;2(1):20. Published 2019 Jun 29. doi:10.1186/s42155-019-0063-3

Q&A

Webinar Chat: In CASE 7: where did the glue migrate to?

Ezio Lanza, MD: We are not completely sure, however, our opinion is that the bright spots we detected were mostly composed of Lipiodol, rather than glue. Even though there are not many reports available to clear this subject, we know that Lipiodol is resolvable, so our guess is that there was a substantial mismatch between the CT image and what was actually happening inside the brain. To validate this theory is also the fact that, if the stroke had been as severe, the symptoms would have been permanent.

Vittorio Pedicini, MD: We know there is some concern around the use of glue in AVM treatment. Some authors claim that glue induces an inflammatory reaction in the vessels, creating some sort of neoangiogenesis. I do not personally remember any such case. Can you share your experience on this subject?

Ezio Lanza, MD: Most of these claims are not based on in vivo studies but rather on lab research. As of today, we have no evidence that alternative embolic agents such as Onyx or Squid do not facilitate AVM re-growth just the same. What we know is that AVMs tend to grow back and that, sooner or later, we will have to treat the patient again. The important thing here is that we have an agent that spreads easily and is effective. Costs also need to be factored in: depending on the agent of choice, some embolization procedures can add up to 50k, which, clearly, can be an issue. At any rate, nobody has yet proven that neoangiogenesis is caused by the agent and not, for instance, by the embolization itself, as a procedure. To validate this theory is also the fact that, if the stroke had been as severe, the symptoms would have been permanent.

Video content handled by Vimeo. To see it you must accept analytic cookies