How the transvenous approach can improve cerebral avm total occlusion? Technical nuances and retrospective analysis of a reference center in France

Introduction: The transvenous approach is new strategy for endovascular management for brain Arteriovenous Malformation (AVM). This technic allows a hight rate of total occlusion with low complications when compared with others approaches. The compression of venous injection technique and the proprieties of liquid embolic agent justify the success of this approach.

Objective: Confirm the the safe and great effectiveness of transvenous approach embolization for selective AVMs. Method: Retrospective analysis for all AVMs treated with venous approach in a reference center in France between May 2017 and November 2017 with review and compression of treatment strategy. Results: Among the analyzed period, 170 patients with 172 AVMs were treated in this institution; 50 patients with 51 AVMs (30%) were treated by venous approach. In this selects group, the venous approach was the last session in all AVMs, 01 patient were death secondary an initial intracerebral hematoma with no complication in the treatment. 48 (94,1%) AVMs have angiogram control in 6 months and the total occlusion was achieved in 47 (92,1%). The total procedure-related complications were 3 (6%), 2 hemorrhagic and 1 ischemic, only 01 patient has significant disability (mRS 4). The hight rates of total occlusion with few complication can be explained by patient selection, the injection technique and the comportment of the liquid embolic agent (retrograde nidal/arterial penetration and late venous occlusion). All AVMs were treated with non-adhesive liquid embolic agent comprised of EVOH (ethylene vinyl alcohol), that retrograde penetrations permit occlusion of artery pedicles with low pressure and little arterial reflux that permit lower ischemic rate. The EVOH property of progressive laminar wall deposition, called “The Porcelain Vein”, permit vein protection and later venous occlusion. The venous occlusion only happens after total exclusion of the nidus and arterial pedicles, avoiding AVM rupture.

Conclusion: This series representing the result of reference neuroradiology center in France and the safe of venous approach when well indicated. The hight rates of cure, 94.7%, with few complications make the venous approach part of strategy in AVM management.