Prediction of the Effect of Injected Ethanol on Pulmonary Arterial Pressure during Sclerotherapy of Arteriovenous Malformations: Relationship with Dose of Ethanol

doi:10.1016/j.jvir.2008.10.012

Journal of Vascular and Interventional Radiology

Volume 20, Issue 1, January 2009, Pages 39-45

https://doi.org/10.1016/j.jvir.2008.10.012 Get rights and content

Purpose

To prospectively evaluate the effect of injected ethanol on pulmonary artery pressure during embolosclerotherapy of arteriovenous malformations (AVMs).

Materials and Methods

This prospective study was conducted in 16 male and 14 female patients (37 sessions; mean age, 34 years; age range, 17–67 years) with AVMs during a 2-year period. The authors measured pulmonary artery pressure via a pulmonary artery catheter and ethanol levels from the pulmonary and radial arteries simultaneously within 3 minutes after each ethanol injection. The authors analyzed the relationship between pulmonary artery pressure and ethanol levels obtained from pulmonary and radial arteries with respect to both single and cumulative doses of ethanol injected. Retrospectively, patients were divided into two groups—those treated with and those treated without vascular occlusion techniques.

Results

The radial arterial ethanol level showed good correlation with the pulmonary arterial ethanol level (r = 0.7). Single dose per injection was statistically related with pulmonary artery pressure (r = 0.5 vs 0.1 and P < .05 vs .29, respectively, in patients treated without and patients treated with vascular occlusion techniques), and the correlation coefficient between cumulative dose and pulmonary artery pressure was 0.2 and 0.3 in respective cases (P < .05 for both). The mean pulmonary artery pressure correlated with pulmonary arterial ethanol level irrespective of the use of vascular occlusion (r = 0.6 for both groups).

Conclusions

Pulmonary artery pressure reflected the pulmonary arterial ethanol level and was positively related to the dose of ethanol. Single dose per injection was predictive of pulmonary artery pressure only in patients treated without vascular occlusion techniques.

Section snippets

Patients

The institutional review board on human study approved this study, and all patients provided written informed consent. This prospective study was conducted in 33 patients diagnosed with AVM undergoing ethanol embolization with a Swan-Ganz catheter for monitoring of pulmonary artery pressure under general anesthesia from September 2005 to August 2007. Patients younger than 16 years were excluded from the study (mean patient age ± standard deviation, 34 years ±10; age range, 17–67 years). Three

Results

The amount of ethanol per injection was 0.06 mL/kg (range, 0.01–0.19 mL/kg). The average pulmonary and radial arterial ethanol levels were 44.5 and 48.2 mg/dL, respectively (range, 1.7–124.5 and 1.0–198.8 mg/dL, respectively) (Table 2). The pulmonary and radial arterial ethanol levels showed good correlation with each other (r = 0.7) (Fig 1). The systolic, mean, and diastolic pulmonary artery pressures obtained after each ethanol injection were 29, 23, and 13 mm Hg, respectively (range, 20–59,

Discussion

The injected ethanol in vascular malformations induces direct tissue toxicity that leads to endothelial damage, severe vascular spasm, and denudation of proteins, which, in turn, leads to the entrapment of erythrocytes in arteries (1, 2). The result of ethanol embolization of AVMs was reported as a 40% cure rate, 28% partial remission, 18% no remission, and 2% of aggravation (18). Ethanol has been favored over other embolic agents because of its relatively good results and low chance of

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Cited by (33)

Efficiency and safety of ethanol sclerotherapy for labial arteriovenous malformations
2022, Journal of Vascular Surgery: Venous and Lymphatic Disorders
Labial arteriovenous malformations (AVMs), usually with accompanying cosmetic defects, pain, and bleeding, are aggressive with a high risk of recurrence and the absence of effective treatment. In the present report, we have described a technique of sclerotherapy for labial AVMs.
Patients with labial AVMs were treated with percutaneous ethanol sclerotherapy with or without polyvinyl alcohol particle embolization. The efficiency, complications, and recurrence rate were analyzed with imaging studies and clinical follow-up data.
All 15 patients had received one or more treatment sessions, of whom 8 had experienced a cure (53.3%) and 5 had experienced remission (33.3%). The two patients who had not experienced an effective result were awaiting further treatment at the last follow-up examination. Four patients (26.7%) who had undergone ethanol sclerotherapy combined with polyvinyl alcohol particle embolization had experienced recurrence. No patient who had undergone only sclerotherapy had developed recurrence at a mean follow-up of 17.2 ± 8.1 months. Thirteen patients had experienced transient complications, including swelling, mild bleeding, and blistering. One patient had a postoperative scar of ∼0.5 cm.
Ethanol sclerotherapy appears effective as a treatment of labial AVMs. Careful application of the treatment could reduce the occurrence of complications.
Therapeutic outcomes of embolotherapy of extremity bone intraosseous arteriovenous malformation with ethanol, coils, and n-butyl cyanoacrylate
2021, Journal of Vascular Surgery
We evaluated the therapeutic outcomes of embolotherapy for bone arteriovenous malformations (AVMs) affecting the extremities using ethanol, coils, and n-butyl cyanoacrylate (NBCA).
We reviewed the data from 36 patients (18 males, 18 females; mean age 25 years; age range, 1-64 years) with bone AVMs affecting their extremities who had undergone embolotherapy using ethanol, coils, and NBCA from December 1996 to July 2019. Of the 36 patients, 19 had had pure bone AVMs and 17 mixed bone and soft tissue (MBS) AVMs. Embolotherapy was performed using direct puncture or a transvenous or an intra-arterial approach (range, 1-18 procedures; mean, 5 procedures). During the 178 embolotherapy procedures, ethanol was used in all 36 patients, except for 1. Coils were used in 14 patients, and NBCA and a lipiodol mixture in 9 patients. The therapeutic outcomes were evaluated by the clinical symptom response and the degree of devascularization on follow-up angiography or computed tomography. The major and minor complications were also evaluated.
The clinical success (cure or markedly improvement) rate of embolotherapy for pure bone AVMs was significantly better than that for the MBS AVMs (88% vs 18%; P < .001). The complete devascularization rate of the bone AVM component of the MBS AVMs was 71%; however, the cure rate of the MBS AVMs was 0% owing to the remaining soft tissue AVMs. Of the 36 patients, 12 experienced complications, including 11 minor (2 skin bullae formation and 10 transient peripheral nerve injury) and 1 major (longstanding nerve palsy).
Embolotherapy for bone AVMs affecting the extremities using ethanol, coils, and an NBCA mixture is effective and safe for the resolution or improvement of symptoms, especially in those with pure bone AVMs.
Systemic Hemodynamic Changes in Low-Dose Ethanol Embolotherapy for Soft-Tissue Arteriovenous Malformations
2021, Chinese Journal of Plastic and Reconstructive Surgery
Ethanol embolotherapy is considered an optimal choice for the treatment of arteriovenous malformations (AVMs); however, there are some complications associated with this treatment. This study aimed to prospectively investigate systemic hemodynamic changes in high-flow AVMs using ethanol embolotherapy.
From September 2012 to September 2014, 34 male patients and 26 female patients with AVMs who underwent embolotherapy (100 sessions in total) with absolute ethanol were included in this study. Invasive systolic blood pressure (SBP) and heart rate (HR) were recorded before and after each injection and throughout the procedure. Differences between the initial and highest SBP (ΔmaxSP) and HR values (ΔmaxHR), as well as the initial and final SBP (ΔSP) and HR (ΔHR) values, were analyzed. We aimed to explore the potential association between these values and the amount of ethanol that was used.
The total ethanol used was variable (0.01–0.40 mL/kg; mean, 0.20 mL/kg). SBP and HR increased after ethanol injection in most sessions (91 in 100 sessions). SBP decreased in 9 sessions (9 in 100 sessions), while HR, oxygen saturation, and end-tidal CO₂ decreased in one of the 9 sessions. ΔmaxSP and ΔmaxHR averaged 38.4 mmHg and 27.8 bpm, respectively (both P<0.05), while ΔSP and ΔHR averaged 3.4 mmHg and 4.0 bpm, respectively (both P<0.05). ΔmaxSP and ΔmaxHR were positively correlated with the total dose of ethanol injected.
Elevations in SBP and HR during ethanol embolotherapy are common, temporary, and most likely pain-mediated; these increases tend to be positively correlated with ethanol dose. Hypotension may be regarded as an acute complication of ethanol embolotherapy. Hypotension combined with bradycardia, oxygen desaturation, and decreased end-tidal CO₂ may be a potential predictor of cardiovascular collapse.
Interventional Management of Arteriovenous Malformations
2019, Techniques in Vascular and Interventional Radiology
Arteriovenous malformations (AVMs) are fast flow malformations characterized by the presence of arteriovenous shunting. These congenital lesions can be evolutive, leading to serious complications such as bleeding, skin ulceration, and cardiac failure. The interventional radiologist plays an important role in the management of these patients. He should be involved in the clinical evaluation to make the proper diagnosis, evaluate the symptoms and potential indication for endovascular treatment. This evaluation should be done in a multidisciplinary clinic with access to plastic surgeons, internal medicine and dermatologist, as well as specific specialists that might need to be implicated (ENT surgeon in the face and neck area, for example). The Schobinger clinical classification is important to assess patient evolution and indicate intervention. We recommend to treat symptomatic or evolutive AVMs. Doppler ultrasound is the first imaging examination that should be performed. Then, MR angiography or computed tomography angiography (CTA) can be proposed depending on the anatomic area involved. Embolization is currently the first line of treatment for these patients. There is currently promising research in the identification of genetic markers and molecular target(s) but there is no recognized pharmacologic treatment for AVM available yet. Digital substraction angiography (DSA) is usually performed for guidance during the embolization session but is also essential to properly classify a specific lesion, according to its anatomy. The anatomic classifications proposed by Cho and Yakes are both useful to choose the best therapeutic approach: Endovascular, direct puncture, retrograde venous approach or a combination of these techniques. Ethanol is the most efficient agent but is at higher risk of skin necrosis and nerve injury and should therefore be used with caution in dangerous territories. Glue and Onyx are liquid agents that are also well suited to occlude the nidus; they can be used in association with ethanol. On the venous side, mechanical occlusion with coils or Amplatzer plugs is mostly used. Again, they can be used in association with a liquid agent (Ethanol, glue or Onyx) to reflux in the nidus. Surgery can be indicated to resect residual AVM following embolization if residual symptoms are present and the planned surgery is feasible, with relative safety.
Subclassification and Treatment Results of Ethanol Embolotherapy of Type II Arteriovenous Malformations of the Extremity and Body
2019, Journal of Vascular and Interventional Radiology
To evaluate the safety and efficacy of ethanol and coil embolization of type II arteriovenous malformation (AVM) according to a new subtype classification.
Eighty-four type II AVMs in the body or extremity of 79 patients who underwent AVM treatment from 1996 to 2017 were retrospectively subclassified according to the angiographic morphology of the draining vein as type IIa (arterioles shunt to focal segment of single draining vein), type IIb (arterioles shunt to venous sac with multiple draining veins), and type IIc (arterioles shunt along long segment of draining vein). Coil and ethanol embolization of the focal or long segment of the draining vein or the venous sac was performed with direct puncture or transvenous approach according to subtype. Treatment outcomes, number of treatment sessions, and complications were analyzed.
AVM cure (ie, complete embolization) rates were 95%, 76%, and 65% in types IIa, IIb, and IIc AVMs, respectively. The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs (P = .015). Median numbers of treatment sessions were 1 in types IIa and IIb AVMs and 2.5 in type IIc AVMs, with a significant difference between type IIc and the other 2 types (P < .05). Minor complications occurred in 20% of patents and major complications occurred in 7%.
The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs, which also required significantly more treatment sessions than the other 2 types.
Percutaneous sclerotherapy for vascular malformations: A systematic review
2014, Annals of Vascular Surgery
Citation Excerpt :
Among a further 198 patients (13 studies) analyzed by Acevedo et al.,26 5 (3%) patients experienced major complications. Very limited evidence suggested that ethanol sclerotherapy (2 case series studies of 53 patients34,35) and STS sclerotherapy (1 case series study of 40 patients18) for AVM resulted in relatively high complication rates. Owing to the large variability in lesion and treatment complexities, the clinical effectiveness of percutaneous sclerotherapy is likely to be highly dependent on proper patient selection.11
This systematic review assessed the available published evidence on the safety and efficacy of percutaneous sclerotherapy for patients with congenital vascular malformations.
A systematic search of various electronic bibliographic databases was conducted in May 2013. A grey literature search was also performed. Study selection, data extraction, and assessment of study quality were undertaken by one reviewer and checked by another reviewer.
One systematic review, one randomized controlled trial, one nonrandomized controlled trial, and 24 case series studies were included. However, deficiencies in reporting, small sample sizes, and marked inter-study heterogeneity precluded a definitive synthesis of the data. Ethanol sclerotherapy appeared to be potentially effective in treating venous malformations, with the majority of patients achieving some lesion regression. However, it is associated with a 16% risk of major complications, including deep tissue injury, deep vein thrombosis, and nerve injury. While there was limited evidence that sclerotherapy with OK-432 was an effective treatment for lymphatic malformations, evidence for the use of sclerotherapy in patients with arteriovenous malformations was unclear.
Very limited evidence from case series studies suggested that sclerotherapy with ethanol and OK-432, administered over multiple sessions, was effective in the treatment of venous and lymphatic malformations, respectively. However, the value of percutaneous sclerotherapy as a pretreatment for or an alternative to surgery is not known. Further evidence is required to delineate which patients will benefit most from percutaneous sclerotherapy to ensure that the advantages of treatment will outweigh the risks.

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: None of the authors have identified a conflict of interest.

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Clinical studyPrediction of the Effect of Injected Ethanol on Pulmonary Arterial Pressure during Sclerotherapy of Arteriovenous Malformations: Relationship with Dose of Ethanol

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Patients

Results

Discussion

Eur J Vasc Endovasc Surg

J Am Coll Surg

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Eur J Pharmacol

Alcohol

Br J Anaesth

How I do it: arteriovenous malformation management

Cardiovasc Intervent Radiol

Embolization of arteriovenous malformations by direct percutaneous puncture

AJR

Symptomatic vascular malformations: ethanol embolotherapy

Radiology

Cardiovascular collapse during ethanol sclerotherapy in a pediatric patient

Paediatr Anaesth

Systemic effects of absolute alcohol embolization in a patient with a congenital arteriovenous malformation of the lower extremity

Anesth Analg

Morbidity in a pediatric patient alcohol ablation of an arteriovenous malformation

Can J Anesth

Acute cardiovascular instability during percutaneous ethanol injection of a hepatocellular carcinoma under general anesthesia

Anesthesiology

Asystole during percutaneous ethanol injection of symptomatic vertebral haemangioma

Anaesth Intensive Care

Clinical study
Prediction of the Effect of Injected Ethanol on Pulmonary Arterial Pressure during Sclerotherapy of Arteriovenous Malformations: Relationship with Dose of Ethanol