A method for complete angiographic obliteration of a brain arteriovenous malformation in a single session through a single pedicle

Abstract

Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been relegated to an adjunctive role to open surgical and radiosurgical methods. In this article, we describe a novel endovascular approach to the treatment of brain AVM using Onyx (ev3 Endovascular, Plymouth, MN, USA), which may allow for a complete angiographic obliteration in a single treatment session. Twelve patients underwent Onyx embolization of an AVM using a novel “reverse plug and push” technique in which a plug is formed around the treatment catheter prior to injecting Onyx into the AVM. The plug mitigates the risk of backflow and catheter entrapment, thereby allowing the user to inject higher volumes of Onyx at higher injection rates. Patient demographics, AVM characteristics, and treatment details were reviewed. Using the “reverse plug then push” technique, an average of 8.8mL of Onyx was injected into the AVM in a single session. In every case, the microcatheter was removed easily with minimal traction pressure. Complete angiographic obliteration was achieved in 83% of patients after a single treatment. Morbidity and mortality were 8% each. The “reverse plug then push” technique allows for a more rapid injection of Onyx due to the formation of a well-controlled plug prior to treatment, mitigating the risk of catheter entrapment by Onyx reflux. With further refinement, this technique may present a viable curative option for treatment of select brain AVM.