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Advances in health and medicine.
Marjorie Bekaert Thomas
Advances in health and medicine.
General Health Channel
Reported November 2, 2012

Removing Dangerous Deformities -- In Depth Doctor's Interview

Monica Pearl, M.D., an Interventional Neuroradiologist at Johns Hopkins, talks about AVMs and the risky procedure that could be life-saving for some patients

What is AVM?

Dr. Monica Pearl: An AVM is a vascular malformation. When thinking about the types of vascular malformations there are low flow vascular malformations or high flow vascular malformations. An AVM is in the high flow vascular malformation category because it has an arterial component. That being said it’s a fast flow lesion.

Do we know how these are formed?

Dr. Monica Pearl: The majority of these lesions are congenital in nature.

How rare are they?

Dr. Monica Pearl:

Extracranial or superficial AVMs are rare and the exact incidence is unknown. These lesions are different from intracranial AVMs, i.e. AVMs inside the brain.

What is a traditional way to remove AVMs?

Dr. Monica Pearl: Traditional approaches for treating arterial venous malformations are via a transarterial approach, meaning from a transfemoral approach. On the inside one goes through the femoral arteries, travels through the arteries inside the brain, and then glues or closes off the AVM from the inside.

From the groin?

Dr. Monica Pearl: Correct.

What did you do in Susan’s case that was difference?

Dr. Monica Pearl: Susan’s case is different because she had multiple previous surgeries and embolization type procedures, but the major paths to her AVM had been closed. Those routes or normal accesses to her AVM were not available, so in order for Dr. Dorafshar, the plastic and reconstructive surgeon with whom I work, to have a safe surgery and resect and reconstruct her lip, he needed me to devascularize her AVM. Since the paths from the inside were no longer available we went from the outside; a direct percutaneous puncture to her lip from the outside in. We use real-time ultrasound guidance. I put an ultrasound on her lip, that way we can identify where the AVM is. Then I put a small butterfly needle and puncture her lip using the ultrasound to guide me, and since it’s a high flow arterial venous malformation one gets prompt return of arterial blood throughout the tubing. Once that’s in place we inject some contrast through the tubing and watch under live fluoroscopy to ensure that you’re in the AVM. When you’re in the AVM and not in normal tissues then it’s safe to glue it. We would then proceed with what’s called the glue embolization.

So you had to be right in the exact spot with that needle?

Dr. Monica Pearl: Yes, that’s the whole purpose of the treatment. It’s to glue the AVM only, but preserve her normal tissue so that she could heal from her surgery.

Has this ever been done before?

Dr. Monica Pearl: It has been done before, here at Hopkins; but the approach is very uncommon because the normal treatment paths are from the inside.

What’s this approach called?

Dr. Monica Pearl: Direct percutaneous embolization.

Did they call it the outside, inside approach?

Dr. Monica Pearl: You can consider that because treatments for AVMs are usually from the inside of the arteries. You go from the femoral artery, travel through the arteries inside the body, and then you attack the AVM from the inside. However, if those pathways are not available then the only other way to get to the AVM is from the outside; so a direct puncture from the outside in.

Was it a successful surgery?

Dr. Monica Pearl: Yes, it was successful and we’re very happy with the procedure. On the angiogram you can see that she has a big AVM, but there was no big arterial feeder that could allow us to access her AVM. So in order for me to devascularize her lesion, you could not do it from the inside. Instead, we went from the outside in and we have a very nice glue distribution throughout her entire AVM, which could not be achieved from the inside.

Your job in this was to go in and just stop the blood flow?

Dr. Monica Pearl:. My job for Susan’s treatment was to devascularize her AVM; remove the blood components of her vascular malformation while preserving her normal tissues. This was so that Dr. Dorafshar could safely remove and resect her AVM the following day but still have normal blood supply to normal surrounding tissues so that she would heal properly.

Is it complex?

Dr. Monica Pearl: Yes.

If you didn’t remove this what would happen to Susan?"

Dr. Monica Pearl: Her AVM would continue to grow with her and she would be fraught with continued nose bleeds, she could rupture her AVM and it could lead to severe blood loss. The natural history of AVMs is they continue to grow with you throughout life. She had so many previous surgeries in the past that she didn’t want to deal with it anymore because of all the complications and the many procedures, but it was becoming so disrupting and disabling with the more frequent nosebleeds, that she had to have something done.

Is she now out of the woods or is there a chance it could come back?

Dr. Monica Pearl: There is a chance that it could come back, however, her embolization and resection couldn’t have been better. That’s really the key for treating these complex vascular malformations, a multidisciplinary approach. As an Interventional Neuroradiologist, I’m able to safely glue Susan’s AVM and prepare her for surgical resection and rescontruction by Dr. Dorafshar.

Personally how rewarding was this to be able to help her?

Dr. Monica Pearl: It’s wonderful, we changed her life. She’s a beautiful woman and she can walk around freely without having to be afraid or embarrassed by anything. It’s gratifying. Now she doesn’t have this big mound of inflamed red tissue in the middle of her face. Instead she smiles proudly and doesn't have to worry about nosebleeds or ridicule.


This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

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If you would like more information, please contact:

David March, MHA
Senior Media Relations Representative/Assistant Director
Johns Hopkins Medicine
(410) 955-1534


To read the full report, Removing Dangerous Deformoties, click here.

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