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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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208
Type of
AV M
Nidus morphologic
structure Description
Angiographic
appearance
IIIb Arteriolovenulous
fistula with dilation
Multiple
shunts between
arterioles and
venules
Complex
vascular
network
Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS,
Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL,
Houdart E, Cordonnier C, Stefani MA, Hartmann A, von
Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K,
Libman R, Barreau X, Moskowitz AJ; international ARUBA
investigators. Medical management with or without interven-
tional therapy for unruptured brain arteriovenous malforma-
tions (ARUBA): a multicentre, non-blinded, randomised
trial. Lancet. 2014 Feb 15;383(9917):614–21.
What was
the main
conclusion
of the “A
Randomized
trial of
Unruptured
Brain
Arteriovenous
Malformations”
(ARUBA)
trial? What
were the main
controversies of
this trial?
Medical management alone is superior to
medical management with interventional
therapy (i.e., neurosurgery, embolization, or
stereotactical radiotherapy) for the prevention
of death or stroke in patients with unruptured
brain AVMs. There were a higher number of
strokes and neurological deficits in patients
in the interventional therapy group. The trial
was criticized because only 13% of screened
patients were randomized in the trial. Majority
of the patients that were excluded had
potentially more aggressive AVMs that are
more representative of brain AVMs in the
community. The mean follow-up of 33months
was too short for a disease with a long natural
history, favoring the medical management
group. Lastly, the small number of patients who
underwent microsurgical resection, the gold
standard in the interventional arm, biased the
trial in favor of medical management.
Cartin-Ceba R, Swanson KL, Krowka MJ.Pulmonary arte-
riovenous malformations. Chest. 2013 Sep;144(3):1033–1044.
C. Hua
https://t.me/med1917
209
Why is it
recommended
that pregnant
patients with
significant
PAVMs undergo
embolotherapy?
There is a high incidence of morbidity
(e.g., paradoxical embolism, hemothorax,
hemoptysis) and mortality in pregnant patients
with PAVM.Embolotherapy in maternal
PAVM regardless of feeding vessel size is
recommended. Embolotherapy has been shown
to be safe and effective after 16weeks of
gestation, and the estimated radiation exposure
to the fetus is minimal when performed by an
experienced interventional radiologist.
Common Questions
What are the
components of an
AVM?
Feeding artery(ies), a nidus, and draining
vein(s)
What is the most
common presenting
symptom in patients
with HHT?
Epistaxis
Where is the most
common location
for PAVM?
Most PAVMs are seen in the lower lobes.
What does ISSVA
stand for and who
are they?
The International Society for the Study of
Vascular Anomalies (ISSVA) is the main
organization responsible in classifying all
vascular lesions.
List the spectrum
of organs involved
with HHT.
Skin and mucous membranes, liver,
gastrointestinal tract, pulmonary, and
central nervous system
23 Arteriovenous Malformation (AVM)
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210
What is the most
common cause of
death in patients
with HHT?
Stroke, brain abscess, or massive
hemoptysis and spontaneous hemothorax
Further Reading
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prognosis of arteriovenous malformations of the brain in adults.
Brain. 2001;124(Pt 10):1900–26.
Arnold R, Chaudry G. Diagnostic imaging of vascular anomalies.
Clin Plast Surg. 2011;38(1):21–9.
Bertino F, Braithwaite KA, Hawkins CM, Gill AE, Briones
MA, Swerdlin R, Milla SS. Congenital limb overgrowth syn-
dromes associated with vascular anomalies. Radiographics.
2019;39(2):491–515.
Blatt J, McLean TW, Castellino SM, Burkhart CN.A review of con-
temporary options for medical management of hemangiomas,
other vascular tumors, and vascular malformations. Pharmacol
Ther. 2013;139(3):327–33.
Burrows PE. Vascular malformations involving the female pelvis.
Semin Interv Radiol. 2008;25(4):347–60.
Cartin-Ceba R, Swanson KL, Krowka MJ.Pulmonary arteriovenous
malformations. Chest. 2013;144(3):1033–44.
Cho SK, Do YS, Kim DI, Kim YW, Shin SW, Park KB, Ko JS, Lee
AR, Choo SW, Choo IW. Peripheral arteriovenous malforma-
tions with a dominant outflow vein: results of ethanol emboliza-
tion. Korean J Radiol. 2008;9(3):258–67.
Cho SK, Do YS, Shin SW, Kim D, Kim YW, Park KB, Kim EJ, Ahn
HJ, Choo SW, Choo IW. Arteriovenous malformations of the
body and extremities: analysis of therapeutic outcomes and
approaches according to a modified angiographic classification.
J Endovasc Ther. 2006;13(4):527–38.
Contegiacomo A, Del Ciello A, Rella R, Attempati N, Coppolino D,
Larici AR, Di Stasi C, Marano G, Manfredi R.Pulmonary arte-
riovenous malformations: what the interventional radiologist
needs to know. Radiol Med. 2019;124(10):973–88.
Do YS, Yakes WF, Shin SW, Lee BB, Kim DI, Liu WC, Shin BS, Kim
DK, Choo SW, Choo IW.Ethanol embolization of arteriovenous
malformations: interim results. Radiology. 2005;235(2):674–82.
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211
Dunham GM, Ingraham CR, Maki JH, Vaidya SS.Finding the nidus:
detection and workup of non-central nervous system arteriove-
nous malformations. Radiographics. 2016;36(3):891–903.
Edmondson AC, Kalish JM. Overgrowth syndromes. J Pediatr
Genet. 2015;4(3):136–43.
Evans RW. Diagnostic testing for the evaluation of headaches.
Neurol Clin. 1996;14(1):1–26.
Faughnan ME, Palda VA, Garcia-Tsao G, Geisthoff UW, McDonald
J, Proctor DD, Spears J, Brown DH, Buscarini E, Chesnutt MS,
Cottin V, Ganguly A, Gossage JR, Guttmacher AE, Hyland RH,
Kennedy SJ, Korzenik J, Mager JJ, Ozanne AP, Piccirillo JF,
Picus D, Plauchu H, Porteous ME, Pyeritz RE, Ross DA, Sabba
C, Swanson K, Terry P, Wallace MC, Westermann CJ, White RI,
Young LH, Zarrabeitia R. HHT Foundation International -
Guidelines Working Group. International guidelines for the
diagnosis and management of hereditary haemorrhagic telangi-
ectasia. J Med Genet. 2011;48(2):73–87.
Gershon AS, Faughnan ME, Chon KS, Pugash RA, Clark JA, Bohan
MJ, Henderson KJ, Hyland RH, White RI Jr. Transcatheter
embolotherapy of maternal pulmonary arteriovenous malforma-
tions during pregnancy. Chest. 2001;119(2):470–7.
Gilbert P, Dubois J, Giroux MF, Soulez G. New treatment
approaches to arteriovenous malformations. Semin Interv
Radiol. 2017;34(3):258–71.
Guimaraes M, Wooster M.Onyx (ethylene-vinyl alcohol copolymer)
in peripheral applications. Semin Interv Radiol. 2011;28(3):350–6.
Guttmacher AE, Marchuck D, Trerotola SO, Pyeritz RE.Hereditary
hemorrhagic telangiectasia, Chap 49. In: Rimoin DL, Pyeritz RE,
Korf BR, editors. Emery and Rimoin’s principles and practice of
medical genetics. 6th ed. Academic Press; 2013.
Hasan M, Rahman M, Hoque S, Zahid Hossain AK, Khondker
L. Propranolol for hemangiomas. Pediatr Surg Int.
2013;29(3):257–62.
Hyodoh H, Hori M, Akiba H, Tamakawa M, Hyodoh K, Hareyama
M. Peripheral vascular malformations: imaging, treatment
approaches, and therapeutic issues. Radiographics. 2005;25(Suppl
1):S159–71.
International Society for the Study of Vascular Anomalies. 2018
ISSVA classification of vascular anomalies. www.issva.org/clas-
sification. Accessed 1 Oct 2018.
23 Arteriovenous Malformation (AVM)
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212
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. Fifth ed. Philadelphia: Wolters Kluwer;
2016.
Keefe NA, Haskal ZJ, Park AW. IR playbook: a comprehensive
introduction to interventional radiology. 1st ed. Springer.
Knopman J, Stieg PE.Management of unruptured brain arteriove-
nous malformations. Lancet. 2014;383(9917):581–3.
Kwon JH, Kim GS. Obstetric iatrogenic arterial injuries of the
uterus: diagnosis with US and treatment with transcatheter arte-
rial embolization. Radiographics. 2002;22(1):35–46.
Lacombe P, Lacout A, Marcy PY, Binsse S, Sellier J, Bensalah
M, Chinet T, Bourgault-Villada I, Blivet S, Roume J, Lesur
G, Blondel JH, Fagnou C, Ozanne A, Chagnon S, El Hajjam
M.Diagnosis and treatment of pulmonary arteriovenous malfor-
mations in hereditary hemorrhagic telangiectasia: an overview.
Diagn Interv Imaging. 2013;94(9):835–48.
Legiehn GM, Heran MK. A step-by-step practical approach to
imaging diagnosis and interventional radiologic therapy in vas-
cular malformations. Semin Interv Radiol. 2010;27(2):209–31.
Lowe LH, Marchant TC, Rivard DC, Scherbel AJ.Vascular malfor-
mations: classification and terminology the radiologist needs to
know. Semin Roentgenol. 2012;47(2):106–17.
Marchuk DA, Guttmacher AE, Penner JA, Ganguly P. Report on
the workshop on Hereditary Hemorrhagic Telangiectasia, July
10-11, 1997. Am J Med Genet. 1998;76:269–73.
Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR,
Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier
C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld
J, Klijn CJ, Harkness K, Libman R, Barreau X.Moskowitz AJ;
international ARUBA investigators. Medical management with
or without interventional therapy for unruptured brain arterio-
venous malformations (ARUBA): a multicentre, non-blinded,
randomised trial. Lancet. 2014;383(9917):614–21.
Monroe EJ. Brief description of ISSVA classification for radiolo-
gists. Tech Vasc Interv Radiol. 2019;22(4):100628.
Oduber CE, Young-Afat DA, van der Wal AC, van Steensel MA,
Hennekam RC, van der Horst CM.The persistent embryonic vein
in Klippel-Trenaunay syndrome. Vasc Med. 2013;18(4):185–91.
Pollak JS, White RI Jr. Distal cross-sectional occlusion is the “key”
to treating pulmonary arteriovenous malformations. J Vasc
Interv Radiol. 2012;23(12):1578–80.
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213
Ratnani R, Sutphin PD, Koshti V, Park H, Chamarthy M, Battaile J,
Kalva SP.Retrospective comparison of pulmonary arteriovenous
malformation embolization with the polytetrafluoroethylene-
covered nitinol microvascular plug, AMPLATZER plug, and
coils in patients with hereditary hemorrhagic telangiectasia. J
Vasc Interv Radiol. 2019;30(7):1089–97.
Rosen RJ, Contractor S.The use of cyanoacrylate adhesives in the
management of congenital vascular malformations. Semin Interv
Radiol. 2004;21(1):59–66.
Sánchez-Morales GE, Anaya-Ayala JE, Serrano-Cueva MA, Salas-
Torrez E, Hinojosa CA.Hand ischemia due to steal syndrome
associated with multiple arteriovenous malformations in a
patient with Parkes-Weber syndrome. J Hand Surg Asian Pac
Vol. 2019;24(1):89–92.
Shovlin CL.Pulmonary arteriovenous malformations. Am J Respir
Crit Care Med. 2014;190(11):1217–28.
Spetzler RF, Martin NA.A proposed grading system for arteriove-
nous malformations. J Neurosurg. 1986;65(4):476–83.
Trerotola SO, Pyeritz RE.PAVM embolization: an update. AJR Am
J Roentgenol. 2010;195(4):837–45.
White RI Jr, Pollak JS, Wirth JA. Pulmonary arteriovenous mal-
formations: diagnosis and transcatheter embolotherapy. J Vasc
Interv Radiol. 1996;7(6):787–804.
Yakes WF.Endovascular Management of High-Flow Arteriovenous
Malformations. Semin Interv Radiol. 2004;21(1):49–58.
23 Arteriovenous Malformation (AVM)
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215© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_24
Evaluating Patient
What are important
questions in determining
access type?
Indication for use
Frequency of use (continuous or
intermittent)
Patient status/length of use (inpatient
or outpatient)
Patient on or at risk for needing
hemodialysis (HD) (i.e., those with
chronic kidney disease (CKD) or
diabetes)
Patient bacteremic or septicemic
What primarily
determines if a non-
tunneled or tunneled line
is needed?
Length of therapy
Chapter 24
Central Venous Access
GauravGadodia
G. Gadodia (*)
Department of Radiology, Imaging Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: ggadodia.md@gmail.com
(continued)
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216
Why is it important to
know if the patient has a
history of chronic kidney
disease (CKD) or diabetes
mellitus (DM)?
Dialysis or potential dialysis patients
should:
Not have peripherally inserted
catheters (PICCs or midlines)
placed so as to preserve
upper extremity veins for
future arteriovenous grafts or
arteriovenous fistulae (AVGs or
AVFs)
Have dialysis access separate from
other needs of central venous
access
Have as small as bore catheters
placed as able (lower risk for SVC
occlusion)
What are the
recommended lab values
to assess for coagulation
status pre-procedurally?
INR
< 2 for non-tunneled lines and
PICCs
< 1.5 for tunneled lines and port
catheters
Platelets
Institution dependent, often the
goal is > 25–30k.
50k is ideal per SIR.
If lower, it is recommended to
have a unit of platelets infusing
during the procedure.
aPTT: No consensus
recommendation
What electrolyte level is
important to measure, and
why?
Potassium, as it should be corrected
prior to procedure if elevated
as there is an increased risk of
arrhythmia with hyperkalemia
What devices should a
patient be evaluated for,
and why?
Pacemakers, defibrillator/AICDs, and
other catheters, as they may decrease
the flow or lumen size of the SVC,
predisposing to complications
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217
What are important
questions to ask the
patient while obtaining
history?
Prior central venous access
procedures and complications
Drug allergies
Especially to anesthetic, sedation,
or contrast (if needed)
Active medications, especially blood
thinners
High Yield History
What general types of
central venous catheters
exist?
Peripherally inserted central catheters
(PICCs)
Centrally inserted central venous
catheters
Non-tunneled
Tunneled
Subcutaneous port
In the appropriate setting,
why might a PICC be
preferred over a tunneled
central venous catheter?
PICCs can be removed in an office or
nursing home, while tunneled central
venous catheters are removed in a
procedural setting.
In the appropriate setting,
why might a tunneled
catheter be preferred over
non-tunneled access?
Tunneling lowers the risk of infection,
along with being more comfortable
for patients and less likely to be
dislodged, making this type of access
more durable and allowing for use in
the outpatient setting.
In the appropriate
setting, why might a
subcutaneous port
catheter be preferred
over a tunneled central
venous catheter?
Easier to hide/better cosmetic
appearance and ability to swim or
bathe
What is a distinguishing
feature of catheters used
for pheresis/dialysis
catheters?
High flow rates (dialysis, 400–
600mL/min, at least > 300mL/min;
pheresis, 150–250mL/min)
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218
Indications/Contraindications
What are general
indications for central
venous access?
Therapeutic
IV fluids/hydration (may be emergent
in settings of resuscitation)
Blood products
Pressors
Plasmapheresis
Hemodialysis
Antibiotics
Ionotropic medications
Chemotherapy
TPN
Other IV medications
Diagnostic
Central venous pressure monitoring
Repeated blood sampling, especially
in patients with poor peripheral
venous access
G. Gadodia
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