Arterial Stentgrafts in Complex Large High-Flow AVM That Failed Conventional Embolization Therapy

Purpose: Endovascular management of peripheral arteriovenous malformations (AVM) commonly involves repeated non-mechanical and/or mechanical embolization. We investigated the use of covered arterial stentgrafts, in combination with embolization, in the management of patients with complex large high-flow limb AVM for treatment of fistulas and flow-related aneurysms.

Materials and Methods: We performed retrospective analysis of six adult patients who received at least one self-expandable covered stentgraft as part of their management. Three patients had Parkes Weber syndrome. Five of the AVM involved a lower extremity, and one involved an upper extremity. AVMs were either of the II, IIIA or IIIB subtype according to Yakes classification. Baseline Schobinger clinical stage prior to stenting was either III or IV, with three patients exhibiting high cardiac output. All patients had non-mechanical and/or mechanical embolization session(s) prior or concomitant to stenting.

Results: 14 stentgrafts were deployed over 8 distinct procedures. Stent deployment was successful in all patients. Clinical success as measured by stable or improved Schobinger stage at 6 weeks was 88%. In four patients, stents remain patent up to date (5-66 months post-intervention). Two patients had failed primary patency, one with stent thrombosis at 36 months with no clinical sequelea and another who underwent amputation at 46 months despite patent stents. Two patients did not require further treatment after 30 months. Minor complications were seen in two patients.

Conclusion: In selected patients with limb AVM, covered arterial stentgrafts may be safe and effective in management of fistulas and flow-related aneurysms as an adjunct to other embolization strategies.