We need more information. What was embolized?
Jim Pawloski, CIRCC
Operative Report
1. Surgical introduction of needle and catheter into the left common femoral artery.
2. Selective catheter placement, arterial system, second-order, left subclavian branch, into the left vertebral artery.
3. Angiography, left vertegral artery, unilateral selective, frontal and lateral digital arteriographic views of skull.
4. Selective catheter placement, arterial system, beyond third order, vertebrobasilar branch, into the thalamoperforating AVM feeding branch off top of basilar artery.
5. Angiography, right thalamoperforating branch AVM feeder, unilateral selective, frontal and lateral digital arteriographic views of skull.
6. Angiography, left vertebral artery, unilateral selective, frontal and lateral digital arteriographic views of skull following first stage embolization.
Endovascular Surgical Procedures: Nonthrombolytic infusion of 1 mg of Brevital into right sided thalamoperforating AVM feeding branch off the top of the basilar artery with extensive neurophysiologic testing of the patient before and after the injection of this agent (including somatosensory evoked potentials, motor evoked responses, and brain stem auditory, evoked responses.)
Findings: Signficant reduction in flow through an extensive midbrain arteriovenous malformation with a single liquid adhesive embolization within a right-sided thalamoperforating branch extending from the top of the basilar artery as described above. The patient will return for several additional sessions of transcatheter embolization to further reduce the size of this AVM nidus.
Procedure: The patient was brought to the neurointerventional operating room suite and was placed upon the procedure table in the supine position. General endotracheal anesthesia was induced and monitored by the anesthesiology staff person in attendance throughout the entirety of the procedure. The patient received IV Ancef prophylactically at the commencemnt of the procedure. The left groin was prepped and draped in a sterile fashion and using standard Seldinger technique, a 5-Frency vascular introduction sheath was advanced intot he left common femoral artery and was secured with skin entry site with 2-0 silk suture. Coaxially through the sheath, a 5-Frency selective catheter was then advanced under Fluroscopic guidance into the proximal left verteral artery where contrast injection was made in order to obtain frontal and lateral digital arteriographic imaging of the skull, which revealed the presence of an extensive deep mid brain arteriovenous malformation fed in a large part by feeders extending from the top of the basilar artery. Poor filling of the posterior cerebral arteries was seen. There was a major draining vein extending laterally to the left to join with the junction between the transverse and sigmoid sinuses. At this junction point, there was a stenosis of this vein indicating some degree of venous outflow-restrictive disease. Coaxially through the 5-Frency catheter, and UltraFlow microcatheter was then advanced under digital roadmap imaging over a Mirage guidewire into a right-sided thalmoperforating feeding branch to the AVM nidus off the top of the basilar artery. With the microcatheter in this location, contrast was carefully injected in order to obtain an angiographic study of the skull which revealed filling of abnormal branches only and no normal parenchymal branch filling. Into this branch, 1 then injected 1 mg of Brevital with detailed neurophysiologic testing of the patient before and after injection of this agent. There was no change from baseline in the patient's somatosensory evoked potentials, motor evoked responses, and brain stem auditory evoked responses. Next, the microcatheter was carefully rinsed with DSW. Through this catheter, I then injected a 33% n-butyl cyanocrylate mixture with Ethiodol. Approximately 0.5 mL of this agent was carefully injected under digital roadmap imaging until antegrade flow arrest was achieved within this thalamoperforating branch. Extensive filling of the AVM nidus was achieved during this ejection. Once the microcatheter was removed, repeat left vertebral digital arteriography was performed, which demonstrated significant reduction of flow through the AVM nidus, although significant throughflow still occurred. There was delayed filling fo the major draining vein further indicating reduced flow through the AVM nidus. It was decided to terminate our efforts after this single liquid adhesive embolization due to fears that more extensive embolization might precipitate an intracranial hemorrhage. There was no change from baseline following the embolization in terms of the patient's somatosensory evoked potentials, motor evoked responses, and brain stem auditory evoked responses. The left groin catheter was then removedd and hemostasis was effected by manual compression. No bleeding or hematoma was noted at the left groin puncture site, which was then covered with a compression dressing. The patient was awakened from general endotracheal anesthesia and was found to be breathing spontaneously and was overall stable. She was then transported to the intensive care unit for further monitoring and care.