Combining reversible electroporation and bleomycin in treatment of arteriovenous malformations

Abstract

Purpose

This study aims to evaluate and compare safety and clinical outcomes of reversible electroporation with either intravenous (BEST) or intraarterial (BEET) Bleomycin application treating extracranial AVMs unsuitable for conventional approaches defined as fine-fistulous AVMs close to vulnerable anatomical structures (such as skin/end-arteries) not amenable for embolization or resection due to inappropriate risk/benefit and/or therapy-refractory or recurrent lesions. Materials and Methods

This is a sub-analysis of the prospective multicenter APOLLON trial (German clinical trial register, DRKS00021019). Clinical and imaging findings were assessed at baseline and 6-month follow-up to evaluate subjective outcome (symptom-free, partial relief, no improvement, clinical progression) and AVM lesion devascularization on MRI (total, 100%; substantial, 76–99%; partial, 51–75%; slight, 50%; progression). BEST versus BEET was at the discretion of the operator; subgroup outcome comparisons were subsequently performed. Results

Twenty-one AVM patients received 31 treatments (16/31 BEST, 51.6%; 15/31 BEET, 48.4%); the mean number of procedures per patient was 1.5 (± 0.7). Complications occurred after 7/31 (22.6%) procedures, including 6.4% major complications (delayed wound healing solved by split-skin transplantation, persistant scarring). Subjective outcome revealed partial symptom relief in 13/21 (61.9%) patients, and 4/21 (19.0%) patients presented symptom-free. In 4/21 (19.0%) patients, no improvement or symptom worsening was reported. Imaging revealed complete devascularization in one case (6.3%), substantial (76–99%) and partial (51–75%) devascularization in 6/16 (36.5%) patients, respectively, while progression was noted in 3/16 (18.8%) patients. Comparison of clinical outcomes differed between both approaches, with BEET being superior to BEST (p = 0.04). Conclusion

The combination of reversible electroporation and bleomycin is effective for treatment of AVMs; BEET tends to present superior to BEST regarding patients ’ outcome.