档案s of Vascular Medicine

研究文章

Transcatheter embolization of congenital vascular malformations, single center experience

Mohammed Habib* and Majed Alshounat

Cardiology Department, Alshifa Hospital, Gaza, Palestine

*通讯地址：穆罕默德·哈比布（Mohammed Habib），医学博士，博士，阿尔西法医院，心脏病学部 - 加沙，巴勒斯坦，电话：009725995140 60;电子邮件：cardiomohammad@yahoo.com

日期：提交：2019年5月22日;Approved:06 June 2019;Published:07 June 2019

How to cite this article:Habib M，Alshounat M.先天性血管畸形，单中心经验的经导管栓塞。Arch Vas Med。2019;3：001-006。doi：10.29328/journal.avm.1001008

版权：© 2019 Habib M, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

先天性血管畸形是罕见的先天性异常，被称为医学实践中最困难和治疗性的神秘疾病之一。

Embolization has rapidly developed in recent years and now represents an integral part of interventional radiology/cardiology practice. Embolization is defined as the percutaneous endovascular application of one or more of a variety of agents or materials to accomplish vascular occlusion.

先天性血管畸形（CVM）可以分为两个主要组：血管瘤和血管畸形。它们代表对治疗的不同反应，预后也不同。该诊断基于临床病史和成像结果。血管瘤是由内皮增生引起的婴儿期的良性血管肿瘤。在血管造影上，血管瘤代表具有小叶图的不规则染色的血管通道。大型喂养动脉将不可视化。这是动脉畸形（AVM）和血管瘤[1]之间的关键区别。相反，血管畸形并未显示内皮细胞增殖。在血管造影上，它们代表复杂的血管nidus，扩张和曲折的喂养动脉和排水静脉[2]。

AVM是罕见的先天性病变。完全消除AVM的Nidus是唯一的潜在治疗[3]。但是，手术切除通常很困难，并且AVM的复发在不完整的切除术中很常见。因此，仅应在手术治疗之前或在手术前或之后与各种栓塞疗法相结合，仅选择外科切除的病变。现在，经导管栓塞在AVM的治疗中起着重要作用[4]。由于与此类异常相关的大量出血风险增加，术前栓塞可能会有所帮助。

病人

记录了我们在欧洲加沙医院的心脏导管插入中心的患者医疗和成像记录的回顾性综述，在讨论了该程序的优势和风险后，从所有患者那里获得了该手术的书面同意。从2008年11月到2014年3月，连续26例患者（3名男性，23名女性）在体内和肢体中有先天性血管畸形，进行了上演的乙醇或线圈栓塞。一名患者以前经历了失败的手术。在26例患者中，乙醇或线圈栓塞被血管外科医生和介入心脏病专家确定为主要治疗方法，此前对患者的临床和成像检查的发现进行了全面审查。先天性血管畸形的诊断是根据临床和成像检查的发现进行的，并且患者通常患有多种症状和症状。最常见的体征和症状是11例患者（46％）的脉动肿块12例（46％）和疼痛（42％）。一名患者（4％）患有充血性心力衰竭，包括努力和心脏肿瘤的呼吸困难。只有两名患者（8％）在溃疡皮肤上出血出血。

栓塞过程

All procedures were performed by 2 experienced interventional cardiologist, ten patients with 16 embolization procedures received local anesthesia. The blood pressure, electrocardiogram, and oxygen saturation, were constantly monitored during the procedure.

Staged ethanol embolization was performed at the nidus itself and not at the vascular feeders; the goal was to embolize all or part of the nidus until complete resolution or improvement of clinical symptoms and signs was achieved. Routes of vascular access to the nidus were chosen after initial angiography. Transarterial, catheterization by using a coaxial catheter and/or percutaneous direct puncture was required to reach the nidus for embolization. The area of percutaneous puncture was prepared and draped. An 18–21-gauge needle was advanced by using fluoroscopic guidance. In most cases, proximal inflow occlusion by over the wire balloons was performed during ethanol injection. After ethanol injections, we waited 5–10 minutes and then performed arteriography to determine completely embolization.

Evaluation of the clinical data and Follow-up results

两位在共识中工作的心脏病专家通过比较基线血管造影和最终血管造影之间的CVM血管化程度（即100％，50-99％或<50％），分析了对乙醇或线圈栓塞的治疗反应。

The clinical outcome of the signs and symptoms (complete or partial resolution, no change, or aggravation) was evaluated. Cure was defined as complete resolution of the signs and symptoms, and 100% devascularization of the CVMs being observed by angiography. Improvement was defined as complete or partial resolution of the signs and symptoms, and 50-99% devascularization of the CVMs observed on angiography. No change was defined as partial resolution or no change of the signs and symptoms, and less than 50% devascularization of the CVMs observed on angiography. Cure and improvement were considered effective therapeutic outcomes of ethanol or coils embolization.

Complications were classified as being either major or minor. The major complications included death, infection, or renal failure as a result of muscle necrosis or permanent adverse sequelae such as permanent nerve injury, brain infarct, the required performance of major therapy and prolonged hospitalization (> 48 hours). Minor complications included any nonpermanent adverse sequelae. (Transient peripheral nerve injury) and skin necrosis.

栓塞前后对患者进行了身体和神经学检查，以评估并发症。当观察到重大并发症时，我们再次审查了血管造影，以发现主要并发症的可能原因。周期性（3个月）随访评估。

Between November 2008 and March 2014, 10 consecutive patients (3 male, 23 female) with congenital vascular malformations in the body and extremities underwent staged ethanol or Coils embolization. The mean age of the patients was 25.9 years (age range, 13– 59 years). During the 16 ethanol embolization performed, the amount of ethanol that was used ranged from 4 to 50 mL in a single embolization session. When maximum amounts of ethanol were used, the total dose did not exceed 1 mL per kilogram of body weight. No patients experienced ethanol toxicity. No patients showed an elevation in creatinine and urea levels, suggesting that renal impairment as a result of hemoglobinuria did not occur during the hospital stay.

According to the angiographic findings, congenital vascular malformation were devascularized 100% in 12 patients, 50% to 99% in 11 patients, less than 50% in 3 patients. The most common complications were reversible skin necrosis.

在16例患者中施用了乙醇栓塞，在9例患者中栓塞栓塞，一名患者的移植支架。

Case of 59- year-old male patient presents with dyspnea on effort and cardiomegaly (Figures 1,2).

Case of 32-year-old woman (patient 1) with right femoral arteriovenous malformations (Figures 3,4).

Case 3 A 26-year-old female patient with pain at third, fourth and five toes (Figures 5,6).

Complications

Three patients (50%) had minor complications during the procedures, two cases of skin necrosis and one case of transient peripheral nerve injury. All cases of skin necrosis were healed with wound dressing, and skin graft was not required. Patients with transient nerve injury recovered completely with time.

一个主要的并发症：据报道，右腿截肢，没有相关的手术死亡率，感染或肾衰竭，导致肌肉坏死或永久神经损伤。

乙醇和线圈已经证明了其在先天性血管畸形管理中的功效。乙醇具有诱导内皮细胞蛋白质变性的独特能力，随后的血管壁剥离和血栓形成。这会导致完全消除，而不是简单的容器管腔障碍物，并且不允许重新开放，因为乙醇会永久损害AVM Nidus的内皮。因此，AVM的乙醇栓塞与出色的结果和结果以及治愈的机会增加相关[5-9]。

For localized CVMs, a single embolization procedure may be sufficient. Embolization of extensive, complex AVMs, however, requires multiple procedures for many reasons.

In patients with a dilated dominant outflow vein, we performed coil embolization. Coil embolization decreases blood flow velocity, which can reduce the amount of ethanol used [10].

为了防止这些并发症，应进行超选择性导管插入术。应将导管放置在Nidus附近，应尽可能多地废除。如果仅闭塞动脉，将很难重复栓塞，例如手术诱使[11]。根据我们的经验，在缺乏或最少的侧支增大时，重复的栓塞疗法是一个月间隔一个月的首选。

We attempted as much as possible to perform embolization by the transarterial approach. Yet, very tortuous vascularity or the presence of adjacent major arterial branches made it necessary to perform additional transvenous or percutaneous embolization [12].

In conclusion, ethanol or coils embolization are an effective treatment for congenital vascular malformations with a high cure rate based on our experience. However, there is a chance of complications with the use of ethanol. It is mandatory to perform long-term follow-up for patients and to accumulate more experience with this technique to lessen the complication rate.

There are some limitations in our study. First, even though our treatment results were good, the number of cases was small. Second, in most cases we used ethanol or coils rather than another embolic agent, and finally if we had treated a larger number of congenital vascular malformations, then a comparative study with other embolic agents might have been necessary and follow-up is necessary to evaluate the long-term efficacy and safety of this treatment technique.