The Apple Strategy

You don’t eat an apple from the core — and you don’t treat an AVM that way either. A practical look at how to build your treatment plan layer by layer.

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Script:

Welcome back. Now I want to talk about something really important — your mindset when you decide to treat an AVM.

You have to make a real decision to commit to curing this AVM. And I don’t mean that you have to cure it by endovascular treatment alone. No, not at all. What I mean is, you have to be committed to helping the patient through the entire journey. Whether it’s embolization, surgery, radiosurgery — or a mix of all of them — you have to own the case.

Because once you start treating the AVM, you become the one who knows it best. You’ve seen it from the inside. You understand the feeders, the veins, the compartments. You’ve done the angios, the planning, the mapping. You’re the one who’s watched it evolve after each session.

So yes, you really have to stick around. You follow up the patient, you support them psychologically, you guide them. Even if you can’t go further with embolization — maybe the anatomy has changed, maybe you hit a technical wall — then you refer, or consult a senior operator, or consider radiosurgery.

But you don’t disappear.

Now let’s talk about how we actually treat the AVM.

Here’s a rough but surprisingly accurate analogy I always use: treating an AVM is like eating an apple.

You never start at the core. You begin at the outer layer and work your way in. Same thing here.

You start with the indirect feeders — the pial collaterals coming from outside the AVM’s main territory.

When you go to embolize these feeders, make sure your microcatheter is well positioned. You don’t want it to be far from the nidus. It needs to be perinidal — right at the end of the artery, as close as possible to the nidus.

Why? Because if you start embolizing from upstream — where the pial collaterals are — your liquid embolic can go into normal brain and cause ischemia. So positioning here is critical.

Then in the next session, you move on to the direct feeders. And I divide these into two types.

First are the micro shunts — the smaller, lower-flow feeders.

Second are the macro shunts — the big, high-flow ones.

And again — always start with the small ones first.

Because if you go for the macro shunt too early, the high flow will carry your embolic straight into the draining vein. And if you occlude that vein while the AVM is still filling — that’s catastrophic.

The pressure builds inside the nidus, and it can rupture. That’s a disaster.

That’s why we always go from small to large. From periphery to center.

And here’s what’s interesting: by the time you reach the final session, the AVM has shrunk. That macro shunt you saw in session one? It’s smaller now. The draining vein? Also smaller.

That’s how you know you’re almost done.

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