| Part I Efficacy of transvenous approach embolization of cerebral arteriovenous malformations and influencing factorsObjective:To assess the safety and efficacy of transvenous approach healing intracranial arteriovenous malformation(BAVM)and its influencing factorsMethod:A retrospective analysis was made of the clinical data of BAVM patients treated with transvenous approach curative embolism at the Cerebrovascular Disease Center of the First Affiliated Hospital of naval military medical university from January 2017 to October 2021,with a total of 54 cases.Some patients undergo transarterial approach embolization before(or at the same time)as transvenous embolization(TVE),and some patients apply temporary blocking techniques for supply arterial balloons,transvenous "pressure cooker" techniques,and controlled antihypertensive pressure reduction.The patients were observed for immediate embolization results,surgical complications and follow-up results,and were divided into complete occlusion group and incomplete occlusion group according to the embolism result.According to the complication situation,it was divided into a complication group and a non-complication group,and the baseline data and vascular construction data of the two groups of patients were compared and analyzed by single-factor and multi-factor Logistics regression analysis,and the relevant influencing factors were explored.Results:(1)Among the 54 patients,50(92.6%)successfully underwent TVE,4 gave up THEIRTV because the microcatheter failed to reach the drainage vein,31 patients(62.0%)received 1 embolization treatment,and 19 patients received>2 embolization treatments.32 patients(64.0%)had arterial approach embolism at the same time or before intravenous approach embolism,of which 8(16.0%)were arteriovenous combined approach embolism.(2)There were 45 cases(90.0%)of complete embolism immediately after surgery,and 3 cases(6.0%)of sub-total embolism,of which 2 cases,and the angiography on the 7th day after surgery showed complete occlusion of the deformity group.After surgery,42 patients received radiographic follow-up,with a median follow-up time of 5.5(3.8,13.3)months[M(Q1,Q3)].There were 39 cases(92.9%)with complete occlusion of malformations,2 cases(4.8%)without progression of residual lesions,and 1 case(2.4%)with recurrence.(3)18 patients(36.0%)developed surgery-related complications,of which 10(20.0%)were hemorrhagic and 8(16.0%)were ischemic,and 15(30%)patients had new neurological defects,with a permanent complication rate of 12%(6/50).All 50 patients received clinical follow-up,the median follow-up time was 25.5(8.8,38.0)months[M(Q1,Q3)],and 42 patients(84.0%)had a good prognosis(mRS ≤2 points),and no new neurological deficit symptoms appeared during the follow-up period.(4)Univariate analysis showed that sex(P=0.048),BAVM(P=0.035)of single dominant drainage veins,and<5 mm(P=0.005)between microcatheters and the initiation end of the vein were factors influencing the complete occlusion of malformational masses;the functional area(P=0.005),the blood supply of the perforated artery was dominant(P=0.031),the S-M grade was higher(P=0.034),the lesion distribution diffusion(P=0.010),and the Buffalo grade was higher(P=0.006)is a relevant influencing factor for postoperative complications.Among which the perforation of the blood supply artery(P=0.033),the diffusion of lesions(P=0.019)were associated with bleeding complications,and the S-M grade(P=0.044)was associated with ischemic complications.In multivariate Logistics regression analysis,the distance between the microcatheter and the initiation of the vein(OR=0.029,95%CI:0.002-0.416,P=0.009)is an independent influencing factor of the occlusion rate immediately after surgery.The diffusion of lesions(OR=5.870,95%CI:1.130-30.482;P=0.035)and the predominance of perforational artery blood supply(OR=4.804,95%CI:1.132-20.385;P=0.033)are independent risk factors for venous approach embolism in the treatment of complications of BAVM.and the closer the distance,the easier it is to achieve complete occlusion;the more diffuse the lesion distribution(OR=5.870,95%CI:1.130-30.482;P=0.035),the more blood is supplied to the perforating artery(OR=4.804,95%).CI:1.132-20.385;P=0.033),the more likely it is to develop perioperative complications.Conclusion:The complete embolization rate of BAVM in the treatment of transvenous approach healing embolism was high,the incidence of permanent surgical complications was low,and the distance between the microcatheter and the beginning of the vein was related to the complete occlusion rate of the malformed mass;the spread of lesions and the perforation of the blood supply artery were independent influencing factors of postoperative complications.Part Ⅱ Transvenous embolization of cerebral arteriovenous malformations Meta-analysisObjective:A meta-analysis was used to investigate the safety and efficacy of transvenous approach embolization in the treatment of brain arteriovenous malformation(BAVM).Method:Our study followed PRISMA guidelines and was primarily designed to explore the outcomes of transvenous embolization treatment for cerebral arteriovenous malformations.Searched 8 databases as of February 14,2022:Pubmed,Embase,Web of Science,Cochrane Library,CNKI,Wanfang,Weipu,CBM and other databases.Data from our Centre are also included.Initial search terms included intracranial arteriovenous malformations,venous approaches,and embolism(see supplementary documentation).The studies identified in the search were then further evaluated to determine inclusion and exclusion criteria,and we included the largest cohort when multiple articles from the same cohort appeared.Studies including transvenous approach embolism in the treatment of cerebral arteriovenous malformations focused on the immediate postoperative occlusion rate and follow-up results of intravenous approach embolism.The secondary outcome of attention is the complication rate.Results:A total of 12 studies with a total of 308 patients and 309 BAVM lesions were included.The complete occlusion rate was 91.0%(95%CI,88%to 94%)immediately after surgery,and the complete occlusion rate at the last follow-up was 96%(95%CI,93%to 99%).The overall postoperative complication rate is 15%(95%CI,9%to 23%),of which the bleeding complication rate is 11%(95%CI,6%to 17%),the ischemic complication rate is 3%(95%CI,2%to 6%),and the overall good prognosis is 90.0%(95%CI,86%to 93%).In subgroup analysis,it can be seen that the immediate postoperative complete occlusion rate of 92%(95%CI,88%-95%)after 2020 is slightly higher than the complete occlusion rate of 90%(95%CI,83%-95%)before 2020 The complication rate after 2020 is 18%(95%CI,9%to 29%)is higher than the complication rate of 11%(95%CI,4%-21%)before 2020.And the univariate analysis of the original data showed that the complications of venous approach embolism in the treatment of cerebral arteriovenous malformation were related to the functional area(P=0.003)and simple deep venous drainage(P<0.05).Conclusion:Transvenous approach embolization therapy for BAVM is safe and effective,with the advantages of high occlusion rate,low complication rate,and a high overall good prognosis rate,In addition,complications of venous approach embolism are associated with functional areas,venous drainage patterns,but large-sample RCT studies are still needed to be further supported. |
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