SIR 2024
Embolization
Arun Kamireddy, MD, MBBS
Research fellow
Johns Hopkins University School of Medicine
Financial relationships: Full list of relationships is listed on the CME information page.
Mohammad MirzaAghazadeh Attari, MBBS, MPH
Postdoctoral fellow
Johns Hopkins University School of Medicine
Disclosure information not submitted.
Alec Jost, MD
Resident
John Hopkins University School of Medicine
Disclosure information not submitted.
Alan J. Kim, BS (he/him/his)
Medical Student
Johns Hopkins University School of Medicine
Financial relationships: Full list of relationships is listed on the CME information page.
Sophia Kemble, RN
HHT Nurse Coordinator
The Johns Hopkins University
Disclosure information not submitted.
Clifford R. Weiss, MD, FSIR
Professor of Radiology and Biomedical Engineering
The Johns Hopkins Hospital
Financial relationships: Full list of relationships is listed on the CME information page.
To provide a comprehensive overview of the various embolization strategies and devices used for managing Pulmonary arteriovenous malformations (PAVMs).
Background: Image-guided transcatheter embolization has become the current standard treatment for PAVMs. It is important to have a broad understanding of the various embolization techniques and devices.
Clinical Findings/Procedure Details:
Guidelines recommend treating all PAVMs seen on imaging, with Feeding Artery Embolization (FAE) being the common method, focusing on area within 1 cm of nidus. However, few studies including Hayashi et al, 2012 and Kajiwara et al, 2014, have highlighted the superior efficacy of Venous Sac Embolization (VSE) over FAE in reperfusion and occlusion rates. Roberts et al, and Nagai et al 2021 demonstrated enhanced outcomes with combined approach, although the applicability of these findings to simple PAVMs remains uncertain. For some specific complex PAVMs, regional or lobar embolization may be an option. The Brockenbrough procedure is a retrograde approach for recanalized aneurysms that requires puncture of interatrial septum to access the pulmonary vein.
Coils and vascular plugs are favored for embolotherapy, as outlined in Table I. In terms of safety, technical success and recanalization, no difference has been observed based on the type of coil. Liquid embolic agents are generally avoided due to the risk of migration. Surgery is reserved for repeatedly failed embolotherapy cases.
Conclusion and/or Teaching Points:
Despite numerous strategies and devices, choosing the best approach for PAVMs is challenging due to their heterogeneity. Continuous research is vital in refining techniques and improving clinical outcomes.