Boston Scientific Corporation · NYSE:BSX
Boston Scientific — Technical Presentation (2006)
23 slides from Boston Scientific's technical presentation, Nov 19, 2006
Slide 1: Arteriovenous Malformations
Arteriovenous Malformations Stanley E. Crawford Symposium 2006 Alan B. Lumsden, MD FACS Professor and Chief Division of Vascular Surgery & Endovascular Therapy Michael E. DeBakey Department of Surgery Baylor College of Medicine
Slide 2: Vascular Lesion Treatment: Arteriovenous Malformation (AVM)
Vascular Lesion Treatment Arteriovenous Malformation (AVM) • Definition - Congenital lesion • Abnormal arteriovenous communications • Feeding arteries • Nidus • Outflow veins • Symptoms • Significant shunting / CV compromise • Pain, neuromuscular dysfunction, tissue ulceration • Hemorrhage
Slide 3: Treatment
Treatment • Absolute indications • Hemorrhage • Ischemia (steal) • Refractory ulceration • Congestive heart failure • Relative indications • Disabling pain • Claudication • Functional impairment
Slide 4: Treatment
Treatment • Conservative • Stockings • Limb elevation • Surgery • 10% lesions • Best after embolization • 100% success when amenable for resection
Slide 5: Vascular Lesion Treatment: AVM Embolization
Vascular Lesion Treatment AVM Embolization • Effective therapy • Destruction of the nidus • Procedural requirements • Superselective access to feeding artery • Injection non-resorbable embolic agent into the nidus • Contour® PVA Particles / Contour SETM Microspheres • Absolute ethanol • n-BCA • .018
Slide 6: Present Understanding of Important Phases of Vascular Development
Present Understanding of Important Phases of Vascular Development Embryology • Stage I Undifferentiated: primitive blood lakes, capillary networks, no veins or arteries • Stage II Retiform: Capillaries form large plexiform structures • Stage III Maturation: Mature vascular channels
Slide 7: Summary of the Most Important Factors Known to be Involved in Vascular Development
Summary of the Most Important Factors Known to be Involved in Vascular Development* Protein/Molecule/Re ceptor Function Deficient Mice/Other Animals FGF Participation in angioblast differentiation from mesoderm No overt abnormalities (formation of "blood islands") VEGF-R2 (Flk-1) EC birth, migration
Slide 8: MRI Classification
MRI Classification Low-Flow Anomalies High-Flow Anomalies T1-weighted image 1. Increased signal intensity when compared 1. Signal voids with fat and skeletal muscle 2. Small amounts of tissue matrix T2-weighted image 1. Decreased signal intensity when compared 1. Signal voids with fat 2. Small amoun
Slide 9: What do we really need to know?
What do we really need to know? • Location: • subcutaneous • deep to fascia • both • Proximity to major structures • sciatic nerve • rectum • Localized or diffuse • Arterial or venous • relative contribution
Slide 10: towel roll
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Slide 11: head rectus femoris foot
head foot rectus femoris femoral nerve branches tensor fascia lata
Slide 12: venous connection
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Slide 13: joint capsule femur
joint capsule femur
Slide 14: Boston,
Boston, Scientific
Slide 15: Treatment
Treatment Embolization • Multiple sessions • Long-term commitment • Usually under general anesthesia
Slide 16: Steps For Safe Embolization
Steps For Safe Embolization • Good preliminary angiography • Think about collateral pathways • Use shortest straightest approach, especially when coils used • Stable catheter position and verify: • Wire if using coils • Contrast if soluble agent • Use non-heparinized saline to flush and dilute contr
Slide 17: Vascular Lesion Treatment: AVM Embolization Hazards
Vascular Lesion Treatment AVM Embolization Hazards • Non-Target Distal embolic embolization • Venous outflow vessels pulmonary circulation • Potentially fatal PE (Pulmonary Embolism) • Prevention • Proper sizing of PVA microspheres / particles • Impact within the nidus • Careful injection of liquid
Slide 18: Non-Resorbable Embolic Agents: Liquid Embolic Agent
Non-Resorbable Embolic Agents: Liquid Embolic Agent n-Butyl Cyanoacrylate (n-BCA) • Description • Tissue adhesive or “glue” • Treatment of cerebral AVMs • Mechanism of action • Polymerization upon contact with ionic fluids • Formation of a solid cast within the vessel • Vessel occlusion • Technique
Slide 19: AVM dorsum left hand
• AVM dorsum left hand • Draining vein punctured • Tourniquet above arterial pressure • 2.5cc absolute ETOH via 3Fr catheter
Slide 20: Radial Head AVM
•Radial Head AVM, multiple vessels feeding venous component. •Catheter inserted into draining vein. •Absolute alcohol injected in 4 stages. •Venogram at 6 months - ablation of veins
Slide 21: Conclusion: AVM Treatment
Conclusion: AVM Treatment 1. These patients lack a home 2. Vascular Surgeons see most of AVM,s 3. No single therapeutic option 4. Need broad oversight 5. Emerging advanced endovascular skills in vascular surgery community 6. Rapid growth of excellent imaging 7. MEN -1 of vascular surgery: patient fo
Slide 22: Contour PVA Particles Instructions for Use
Contour PVA Particles Instructions for Use: Refer to the operator's manual for complete instructions for use. Indications Contour Emboli are used for the embolization of hyper vascular tumors and arteriovenous malformations. Contraindications Patient intolerance to temporary occlusion procedures. Va
Slide 23: Contour SE Microspheres Instructions for Use
Contour SE Microspheres Instructions for Use: Refer to the operator's manual for complete instructions for use. Indications Contour SE Microspheres may be used for the embolization of hypervascular tumors and arteriovenous malformations (AVMs). Contraindications Patient intolerance to occlusion proc