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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3609_Библиотеки_им_академика_М_И_Перельмана
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R. Kumar et al.
Fig. 30.27 The upper set of images are from the MR exploration of the bleed, and the lower panel images are from the VR reconstruction of the
entire AVM, showing exclusive supply from the anterior choroidal artery and drainage into the basal vein of Rosenthal
30 Endovascular Approach forCurative Embolization ofBrain AVMs: Insights fromAngio-architectonics andAngio-anatomy
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Fig. 30.28 Super-selective angiographic exploration of the nidus. The
intranidal weak points are identied. It is interesting to see that out of
the many pedicles studied, less than one-third of those were embolized,
as the target here was a subtotal embolization. A total curative embolization in this situation will denitely produce xed decits
Fig. 30.29 The upper panel shows the section of the AVM in the sagittal orientation, and the bottom pane shows the deposition of the embolic
material, strictly within the nidal weak points
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Fig. 30.30 The sequential
images obtained during the
embolization of the anterior
choroidal AVM.In the
baseline image, the entire
AVM and the draining vein
are seen lling early and
briskly. As the embolization
progresses, there is a
slowing of ow in the
draining vein with
stagnation. With further
embolization, there is a
signicant stagnation seen
in the arterial end of the
nidus as well. The
procedure is stopped when
no more early shunting in
the basal vein of Rosenthal
is seen
R. Kumar et al.
Fig. 30.31 A.Right
radial access
angiogram.
B.Demonstration of
guide easily climbing
up the bovine origin left
CCA.C. Parietal
Neopallial AVM.D.
Post-embolization onyx
cast
c d
30 Endovascular Approach forCurative Embolization ofBrain AVMs: Insights fromAngio-architectonics andAngio-anatomy
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Fig. 30.32 A summary of the different patterns of supply to the nidus
of an AVM.The so-called en-passage feeders are basically the medullary perforators originating from the ascending and descending sulcal
as well as the transverse gyral segments of the leptomeningeal arcade.
As previously thought, these are not untouchable and can be very well
Complications ofAVM Embolization
1. Ischemic Complications
Ischemic complications may arise due to the migration of
the embolic agent into normal vasculature, especially if the
main arterial feeder supplies normal brain tissue beyond the
AVM (the en-passage type feeder seen in gyral AVMs) or if
there is excessive reux of the embolic material into the
proximal part and/or branches of the feeding artery. In the
former case, selective catheterization of the arteries that
branch out from the main artery to supply the AVM should
be attempted, and embolization should be done via those
branches if possible. The latter complication can be avoided
by using the pressure cooker technique.
2. Haemorrhagic Complications
Haemorrhage can occur due to the rise of intranidal
pressure due to early occlusion of the venous outow
before complete intranidal occlusion, persistence of nonoccluded shunts, partial occlusion, regrowth of AVM,
arterial perforation by the microguidewire or microcatheter, or vessel rupture while withdrawing the microcatheter, especially if it is trapped by reuxed embolic
material or while applying the pressure cooker technique.
To avoid such complications, AVM embolization should
ideally be done in a single session, complete nidal
occlusion should be done, any non-occluded shunt needs
to be identied and occluded, venous outow should be
preserved until complete intranidal deposition of the
embolic material, and careful handling of the endovascular instruments is desired.
catheterized and embolized as seen in various examples in this manuscript. The direct supply with the vessel terminating in the nidus is the
most desirable but found in less than a third of cases. Perinidal vessels
do not participate in the shunt and are therefore supposed to be left
alone
Conclusions
Brain AVMs are eminently amenable to endovascular
curative embolization. Most of the available classication
schemes are basically indicators of surgical difculty during excision and have no bearing on the possible endovascular occlusion rates. Also, the size of a given AVM only
increases the procedure duration and the number of catheterizations and has no bearing on the ultimate success
rates of intervention. Super-selective, intranidal injections
of embolic material like NBCA has the potential to cure
many of these lesions. The success rates of curative embolization are approximately 70% with excellent long-term
stable results. With the evolution of technology, we expect
these to reach approximately 80% in the coming years.
The single most important factor that leads to good outcomes is an understanding of the Nidal and Perinidal
Angio-architecture (Fig.30.32). In certain situations like
deep-seated choroidal AVMs, a curative embolization is
not possible without producing decits, and therefore a
subtotal embolization is the way to go. Apart from these
exceptions, most AVMs should be studied in detail prior
to embarking on an embolization, and the aim at the outset should be to offer a cure, either in a single session or
in multiple staged procedures. The choice of material
should always depend on the experience and comfort of
the primary operator. There are “safety points” in each
vascular territory, beyond which any embolization does
not produce any decits, and the primary aim of catheterization should always be to cross these points.
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References
1. Valavanis A, Pangalu A, Tanaka M.Endovascular treatment of cerebral arteriovenous malformations with emphasis on the curative
role of embolisation. Interv Neuroradiol. 2005;11(Suppl 1):37–43.
2. Potts MB, Zumofen DW, Raz E, etal. Curing arteriovenous malformations using embolization. Neurosurg Focus. 2014;37(3):E19.
3. Mohr JP, Overbey JR, Hartmann A, etal. Aruba co-investigators.
Medical management with interventional therapy versus medical
management alone for unruptured brain arteriovenous malformations (Aruba): nal follow-up of a multicentre, non-blinded, randomised controlled trial. Lancet Neurol. 2020;19(7):573–81.
4. Luessenhop AJ, Spence WT. Articial embolization of cerebral
arteries. Report of use in a case of arteriovenous malformation. J
Am Med Assoc. 1960;172:1153–5.
5. Houdart E, Labeyrie MA, Lenck S, etal. Treatment of AVM: endovascular methods. In: Beneš V, Bradáč O, editors. Brain arteriovenous malformations. Cham: Springer; 2017.
6. Vollherbst DF, Chapot R, Bendszus M, et al. Glue, onyx, squid
or PHIL? Liquid embolic agents for the embolization of cerebral
arteriovenous malformations and Dural arteriovenous stulas. Clin
Neuroradiol. 2022;32(1):25–38.
7. Sorimachi T, Koike T, Takeuchi S, etal. Embolization of cerebral
arteriovenous malformations achieved with polyvinyl alcohol particles: angiographic reappearance and complications. AJNR Am J
Neuroradiol. 1999;20(7):1323–8.
8. Chapot R, Stracke P, Velasco A, etal. The pressure cooker technique
for the treatment of brain AVMs. J Neuroradiol. 2014;41(1):87–91.
9. Massoud TF, Hademenos GJ.Transvenous retrograde nidus sclerotherapy under controlled hypotension (TRENSH): a newly proposed treatment for brain arteriovenous malformations—concepts
and rationale. Neurosurgery. 1999;45(2):351–63; discussion 363–5.
10. Koyanagi M, Mosimann PJ, Nordmeyer H, etal. The transvenous
retrograde pressure cooker technique for the curative embolization
of high-grade brain arteriovenous malformations. J Neurointerv
Surg. 2021;13(7):637–41.
Part IV
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Splachnic Artery Disease
Angioplasty andStenting
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oftheMesenteric Arteries
AntoineGirault, PaulineFillet, andQuentinPellenc
31
Abbreviations
AMI Acute mesenteric ischemia
BS Bare stent
CA Celiac artery
CMI Chronic mesenteric ischemia
CS Covered stent
CTA Computed tomography angiography
DUS Duplex ultra sounds
IMA Inferior mesenteric artery
SMA Superior mesenteric artery
Case Presentation
A 78-year-old man was referred to emergency department
due to acute abdominal pain evolving for 2weeks.
Active smoker, he was known to be treated for an ischemic cardio-myopathy (coronary stenting) and peripheral
arterial disease (femoral endarterectomy). He presented
post-prandial abdominal pains and an 8kg loss of weight in
the past 2months but did not come in consultation due to
national pandemic lockdown. He described one episode of
melena the day before. Clinical ndings show periumbilical
spontaneous pain with no peritoneal signs, bilateral femoral
pulse but no popliteal or distal pulses. Blood test revealed
14,000/mL leucocytes, C-reactive protein: 33mg/L, and lactate: 1.6mmol/L.
Emergent CTA showed an atheromatous aorta with ostial
occlusion of the superior mesenteric artery (SMA) followed
by tight stenosis, mild stenosis of the coeliac trunk (CT),
occlusion of inferior mesenteric artery (IMA), and atheromatous inltration of both hypogastric arteries. No bowel dilatation or wall perfusion attenuation was observed on CT scan
(Fig.31.1).
Continued at page 336
A. Girault
Department of Vascular and Thoracic Surgery, Hôpital Marie
Lannelongue, Groupe Hospitalier Paris-Saint Joseph, Université
Paris-Saclay, Paris, France
e-mail: Unknown0007871@Springer.com
P. Fillet · Q. Pellenc (*)
Vascular and Endovascular Surgery Unit, Clinique de Genolier,
Swiss Medical Network, Genolier, Switzerland
Department of Vascular and Endovascular Surgery, La Cote
Healthcare Group, Morges, Lausanne, Switzerland
e-mail: unknown0199@springer.com; quentin.pellenc@ehc.vd.ch
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_31
Fig. 31.1 CT angiography of SMA occlusion with instable bowel
ischemia complicating chronic occlusion. Short calcied occlusion followed by tight stenosis
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Background
Mesenteric ischemia (MI) is dened by an acute or a
chronic bowel perfusion insufciency that can be caused by
arterial obstruction, venous thrombosis or by non-occlusive
diseases [1, 2]. Arterial acute or chronic occlusive disease
represents 90% of MI and diagnosis is pointed after the
conjunction of non-specic clinical and biological signs
and more specics radiological signs [3]. Treatment
included a multimodal strategy proposed by a multidisciplinary team and including a rapid assessment of the
patient, a specic medical treatment, a rapid and specic
bowel revascularization +/− resection and dedicated postoperative cares [4–6].
Endovascular therapy is now the treatment of choice for
arterial acute and chronic mesenteric ischemia, leading to a
decreased perioperative morbidity and mortality, a shorter
length of hospital stay and faster recovery, compared to open
repair [3, 7–10].
Atheromatous stenosis is the cause of 65% of acute mesenteric ischemia (AMI) and represents the vast majority of
chronic mesenteric ischemia causes (CMI) [3]. In this chapter, angioplasty and stenting of atheromatous stenosis of the
celiac artery (CA) and the superior mesenteric artery (SAM)
will be developed.
Indications forTreatment
Indication for mesenteric artery revascularization is based on
a bundle of clinical and radiological arguments.
Revascularization is indicated for symptomatic patients
associated with a SMA or CA stenosis ≥70% or CA≥70%
and SMA≥50% [7]. Symptoms depend on the type of mesenteric ischemia:
1. Chronic mesenteric ischemia is revealed by postprandial
chronic abdominal pain, food fear, weight loss, and
diarrhea.
2. Acute ischemia complicating chronic mesenteric isch-
emia or asymptomatic SMA stenosis (Acute-on-chronic).
Clinical presentation is dominated by brutal or rapidly
progressive abdominal pain, with or without vomiting,
diarrhea, and gastrointestinal bleeding.
Prophylactic stenting of the SMA in asymptomatic mesenteric occlusive disease patients remains controversial but
may have a role in patients with severe three-vessel stenosis
and in patients with a signicant SMA stenosis planned for
major surgery as aortic surgery, cardiopulmonary bypass etc.
[7]. Bowel surgery such as left colonic resection could also
be preceded by SMA prophylactic stenting in poorly vascu-
larized patients. The nal decision will be approved during a
multidisciplinary discussion.
The SMA remains the primary target artery for revascularization of chronic and acute-on-chronic mesenteric
ischemia regarding the vast territory and the collaterals
fed by this artery [3]. The coeliac trunk will be stented in
case of persistent ischemia after the SMA revascularization [11] or in case of supramesocolic ischemia [3]. Of
course, CA should not be dilated and stented if there is
active compression by the median arcuate ligament [3].
Timing forOperation
Early stage of AMI is reversible arguing the need of an emergent revascularization and medical therapy to save longer
bowel segment [5, 6, 12]. Experience of dedicated intestinal
stroke centers showed a decreased time between initial pain
and revascularization at the acute phase of mesenteric ischemia. As already described in the neurovascular stroke centers, those centers should become high-volume centers by
centralizing this activity [6]. Intestinal stroke center includes a
multidisciplinary team with gastroenterologist, general surgeons, vascular surgeons, radiologists, and anesthesiologists.
Endovascular surgery is the rst line treatment at the early
stage of acute mesenteric ischemia in patients who don’t
need laparotomy for bowel resection. Usually, surgical open
or hybrid revascularization is performed when laparotomy is
required. The following signs go usually together with
advanced bowel necrosis: clinical signs of peritonitis, lactate
>2 mmol/L, organ failure, Biological inammation (CRP
>150mg/L), and signs of bowels suffering the CT scan (see
below) [13–15].
In CMI, medical therapy alone is not recommended arguing the need of revascularization in the majority of the
patients [8]. Furthermore, total parenteral nutrition is not an
acceptable alternative to revascularization but could improve
patient general status before surgical revascularization in
patient not suitable for endovascular repair.
Preoperative Assessment
Preoperative nutritional status has to be assessed before revascularization especially in CMI. Malnutrition is associated with
an increased risk of postoperative mortality after endovascular
and open surgical revascularization [16]. Restoring mesenteric
circulation has priority and should not be delayed by attempts
to improve nutritional status except in case deep malnutrition
and open surgical revascularization planned.
Upper gastrointestinal endoscopy or colonoscopy are
essential in the work-up of patients suspected of having
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chronic mesenteric ischemia, mainly for exclusion of
differential diagnoses. But a normal endoscopy does not
exclude a CMI [7].
No plasma marker has a high specicity in AMI. The
L-lactate has a prognosis role and is elevated in late presentation of AMI [14]. Systemic inammatory response syndrome
induced by IMA leads to hyperleukocytosis and increase of
C-Reactive protein which are also biologicals signs of
advanced ischemia.
Duplex ultra sound (DUS) is not an appropriate imaging
method to assess acute occlusive lesions of the visceral arteries [3]. In CMI, DUS is the recommended exam for screening
patients with chronic mesenteric occlusive disease. It allows
visualization of CA and SMA in almost 100% of the cases
[17] and provides a diagnostic accuracy of 80–90% for the
detection of >70% mesenteric arteries stenosis compared to
angiography. A 70% stenosis is usually associated with a
peak systolic velocity of 200–320cm/s in the CA and 205–
400cm/s in the SMA [3, 7]. Postprandial testing can be helpful in atypical clinical presentation of CMI. Furthermore,
mesenteric arteries hemodynamic are strongly inuenced by
respiratory cycle and conditions of exam have to be notied.
Computed tomography angiography (CTA) as the preferred denitive imaging test for acute and chronic mesenteric occlusive disease is recommended [3, 7, 8]. A triphasic
CTA with 1mm slices should be the gold-standard especially
in case of AMI. It conrms the arterial etiology of AMI and
allows the characterization of the stenosis/occlusion (length,
calcications, distal artery diameter, positions of collaterals,
distal outow). Furthermore, CTA is an essential tool for
evaluation of the ilio-femoral access or subclavian access in
case of stenting. Assessment of bowel suffering is also a
main point. Advanced-stage AMI radiological features
include bowel dilatation >2.5 cm, enhancement default,
pneumatosis, and portomesenteric venous gas [13, 14].
Table 31.1 Suggested Endovascular Toolkit for the endovascular
revascularization of superior mesenteric artery. Suggested options
based on the author’s experience in order to face most of cases
Manufacturer Size/length
Wires
Any standard access wire
Radiofocus Glidewire
oppy
Advantage Glidewire Terumo
Rosen Cook medical
Gladius MG Asahi
Sheaths
Any standard access sheath Any 6-7 Fr/11cm
Steerable sheath Medtronic
Catheters
Bern catheter Boscton scientic
Quick cross support (low
prole)
Vertebral Terumo
Micro catheter Terumo Progreat 2.8 Fr
Balloons
Mustang 0.035″
Ballons expandable covered stent
Advanta V12 Gettinge 5–8mm
Self expandable stent
Absolut pro Abbott 6–7mm
Rentry catheter
Outback Cordis
Atherectomy device
Jetstream 2.4/3.4 Boston scientic 7 Fr
Thrombectomy devices
Thrombus aspiration
catheter
Angiojet with Solent™
Proxi catheter
Terumo
Tourguide
Spectranetics/
Phillips
Glidecath
Boscton scientic 3–7mm
OptiMed
BigLumen
Boston scientic 6 Fr
0.035″
0.035″
0.035″
0.035″
0.018″
7 Fr/55cm
0.035″/4 Fr/100cm
0.018″-0.035″/4
Fr/65-90cm
0.035″/4 Fr/100cm
6, 7, 8 Fr
Endovascular Surgery andTechnique
Basic endovascular toolkit:
– Short 6 Fr sheath
– Standard oppy hydrophilic guidewire
– Selective catheters (Bern, Rim, Cobra, etc.)
– Stiff guidewire (Rosen)
– Long 7 Fr sheath 45cm
– Steerable 7 Fr long sheath
– Predilatation balloon angioplasty: 4–5mm×20–40mm
– Balloon expandable covered stent (7 mm × 22 mm,
7mm×26mm, 7mm×32mm)
– Auto-expandable nitinol bare stent (7mm× 30mm and
6mm×30mm)
A list of suggested material is summarized in Table31.1.
Antegrade Access
Femoral access remains the rst line approach. In the past
years, most of cases were performed using a 6 or 7 Fr angulated long sheath with a success rate of 85% of femoral
access in a study from our group [18].
When angulation of the SMA was not favorable or in case
of occlusion requiring more support, an antegrade approach
from above through a brachial puncture was needed.
Classically using a 90-cm-long 7 Fr sheath, brachial access
allows easily the SMA catheterization. The main issue
remains the SMA occlusion case requiring heavy guidewire
support to recanalize the artery. The trick consists, after
sheath valve puncture, of the placement of a super stiff
parallel guidewire into to one iliac artery. This technique
offers a good stabilization of the long sheath distal end.
The use of steerable sheaths appears to be a game changer
in vascular surgeons’ practices. This type of devices has been
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Fig. 31.2 Persistent supramesocolic acute ischemia 3days after emergent stenting of the SMA for acute-on-chronic mesenteric ischemia in a
69-year-old woman in postoperative course of coronary bypass operation with a past history of aorto-bifemoral bypass and right renal artery
stenting. CTA showing a tight ostial stenosis of the CA and proper
widely used to delivered bridging stents in branched endovascular aortic repair through femoral access avoiding upper
body approaches and their complications [19]. The steerable
sheath allows a downward orientation in the axis of the SMA
or CA and provides efcient support to allow artery recanalization leading to a high success rate of the femoral access
[18] (Figs.31.2 and 31.3).
Retrograde Access
In case of antegrade access failure, a retrograde open mesenteric artery stenting (ROMS) can be proposed [20, 21].
This technique needs a laparotomy and a mesenteric surgical access. It is usually performed when concomitant bowel
resection is mandatory. It can be associated with distal endarterectomy and patch angioplasty in case of long stenosis.
It does not need aortic or iliac artery cross clamping and
may avoid to require to an open surgical revascularization
using arterial bypass exposing the risk on graft infection in
those septic conditions. Indication of ROMS in case of
endovascular antegrade SMA approach failure decreased
dramatically since the development of new steerable sheaths
(personal data).
The ROMS needs a surgical approach of SMA in the root
of the mesentery. Rarely, SMA is just punctured, and a 7 Fr
sheath is inserted retrogradely. In most of cases, ROMS is
patency of the SMA covered stent (left panel). CA is catheterized using
a 7 Fr Tourguide long sheath (Medtronic) and an 8×17mm iCover
stent (iVascular) is positioned on a 0.035″ Rosen guidewire (middle
panel). After stent delivery (right panel)
Fig. 31.3 Final angiography with synchronous enhancement of CA
and SMA
associated with an open thrombo-endarterectomy and patch
angioplasty. All collaterals have to be controlled and clamped
with silicon loops and proximal artery is standardly cross
clamped. Regarding the risk of bowel resections, prosthetic
patches are less used than autologous saphenous patch or
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