Soulez Gilles, Gilbert Md Frcpc Patrick, Giroux Md Frcpc Marie-France, Racicot Md Frcpc Jean-Nicolas, Dubois Josée
Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Québec, Canada; Department of Radiology, Radiation-Oncology and Nuclear Medicine, Université de Montréal, Montreal, Québec, Canada; Institute of Biomedical engineering, Université de Montréal, Montréal, Québec, Canada; Laboratory of Clinical Imaging Processing, Centre hospitalier de l'Université de Montréal (CHUM) Research Center (CRCHUM), Montréal, Québec, Canada.
Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Québec, Canada; Department of Radiology, Radiation-Oncology and Nuclear Medicine, Université de Montréal, Montreal, Québec, Canada.
Tech Vasc Interv Radiol. 2019 Dec;22(4):100633. doi: 10.1016/j.tvir.2019.100633. Epub 2019 Oct 16.
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.
动静脉畸形（AVM）是一种以动静脉分流为特征的高流量畸形。这些先天性病变可能会发展，导致严重并发症，如出血、皮肤溃疡和心力衰竭。介入放射科医生在这些患者的管理中起着重要作用。他应参与临床评估以做出正确诊断，评估症状以及血管内治疗的潜在指征。这种评估应在多学科诊所进行，该诊所应能接触到整形外科医生、内科医生和皮肤科医生，以及可能需要参与的特定专科医生（例如面部和颈部区域的耳鼻喉科医生）。Schobinger临床分类对于评估患者病情发展和指导干预很重要。我们建议治疗有症状的或进展性的AVM。多普勒超声是首先应进行的影像学检查。然后，根据所涉及的解剖区域，可以建议进行磁共振血管造影或计算机断层血管造影（CTA）。栓塞术目前是这些患者的一线治疗方法。目前在基因标志物和分子靶点的识别方面有很有前景的研究，但目前尚无公认的针对AVM的药物治疗方法。数字减影血管造影（DSA）通常在栓塞过程中用于引导，但根据病变的解剖结构对特定病变进行正确分类也至关重要。Cho和Yakes提出的解剖学分类对于选择最佳治疗方法都很有用：血管内治疗、直接穿刺、逆行静脉入路或这些技术的联合应用。乙醇是最有效的药物，但皮肤坏死和神经损伤的风险较高，因此在危险区域应谨慎使用。胶水和Onyx是液体栓塞剂，也非常适合闭塞畸形灶；它们可以与乙醇联合使用。在静脉侧，主要使用线圈或Amplatzer封堵器进行机械闭塞。同样，它们可以与液体栓塞剂（乙醇、胶水或Onyx）联合使用，以反流至畸形灶。如果存在残留症状且计划的手术可行且相对安全，则可考虑在栓塞后手术切除残留的AVM。
