Vein-first embolization is superior to transarterial approach in type IIIb arteriovenous malformations

Jun Gon Kim; Sang Yub Lee; Kwang Bo Park; Dongho Hyun; Sung Wook Shin; Sung Ki Cho; Hong Suk Park; Sung Wook Choo; Young Soo Do

doi:10.1016/j.jvsv.2025.102274

Vein-first embolization is superior to transarterial approach in type IIIb arteriovenous malformations

J Vasc Surg Venous Lymphat Disord. 2025 Jun 6;13(5):102274. doi: 10.1016/j.jvsv.2025.102274. Online ahead of print.

Authors

Jun Gon Kim¹, Sang Yub Lee², Kwang Bo Park¹, Dongho Hyun¹, Sung Wook Shin¹, Sung Ki Cho¹, Hong Suk Park¹, Sung Wook Choo¹, Young Soo Do³

Affiliations

¹ Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
² Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Electronic address: sangyub@skku.edu.
³ Department of Radiology, Hallym University Sacred Heart Hospital, Seoul, Korea.

PMID: 40484230
DOI: 10.1016/j.jvsv.2025.102274

Abstract

Objective: To propose a modified treatment concept for type IIIb arteriovenous malformation (AVM), involving a vein-first (VF) strategy that focuses on direct puncture and coil embolization of dilated veins, followed by ethanol injection from the vein to feeding arteries. This retrospective study evaluated the safety and efficacy of this approach.

Methods: A total of 117 patients (55 males; median age, 27 years) with type IIIb AVMs were retrospectively reviewed. Patients were divided into two groups: a transarterial (TA) embolization-dominant group and a VF group, which underwent direct puncture of veins with coil embolization followed by ethanol injection. AVM characteristics, embolization techniques, number of treatment sessions, angiographic outcomes, and procedure-related adverse events were analyzed.

Results: A total of 515 procedures were performed: 117 in the VF group (n = 41) and 343 in the TA group (n = 76). No significant differences in demographics or AVM characteristics were found. The VF group achieved significantly better treatment outcomes than the TA group (88% vs 51% achieving >90% lesion improvement; P = .001). The VF group required a median of 4.2 treatment sessions per patient vs 4.5 in the TA group, and used 129 mL vs 141 mL of ethanol; those differences were not statistically significant. Procedure-related adverse events were significantly lower in the VF group (11%) than in the TA group (22.3%; P = .0009).

Conclusions: The VF strategy for type IIIb AVM achieved better outcomes and fewer adverse events than conventional TA embolization technique.

Keywords: Adverse events; Arteriovenous malformations; Direct puncture; Embolization; Treatment outcome; Vein first.