E-120 novel double catheter technique with detachable microcatheter for treatment of arteriovenous malformations

Abstract

Onyx has improved the curative rates of embolization as it allows for more controlled injection over a period of time. 1 We describe a new double arterial catheterization technique using a detachable tip micro catheter in conjunction with a second micro catheter to form a proximal Onyx plug to treat an AVM with better penetration. A 21 year old male with a known ruptured AVM presented for elective staged treatment. Cerebral DSA showed a right frontal SM grade 5 AVM with MCA and ACA feeders. In the fifth session, through a guiding catheter, an Echelon-10 micro catheter was advanced, with the help of 0.08-inch microguidewire (Mirage, ev3) to access a distal M4 branch supplying the AVM. An Apollo™ 3cm detachable tip microcatheter was navigated alongside the first catheter in the same feeder but more distally into the nidus. The Echelon micro catheter tip was positioned between the most distal marker and the detachment zone of Apollo and an Onyx plug created to prevent reflux. It was then removed and the Apollo microcatheter was used to inject Onyx 18 into the nidus of the AVM. After embolization was confirmed by control angiogram, the Apollo tip was detached and micro catheter removed under fluoroscopic guidance. Flow was eliminated through a significant portion of the nidus using this technique. The patient remained hemodynamically stable throughout the procedure and no immediate complications were noted Discussion Inadvertent occlusion of the draining vein before complete occlusion of the nidus and reflux around the delivery micro catheter into important normal arterial branches remain a major challenge. 2 To overcome these limitations, we used a second micro catheter to form an Onyx plug to create a seal around the distally placed detachable tip. 3 This wedge flow condition reduced the blood supply and contrast washout during selective injections. It prevented Onyx from reflux into important vessels and allowed for more forceful and thorough embolization. Chapot et al . 4 described a “pressure-cooker” technique based on a similar concept but used coils and glue to form the plug which makes it more challenging and risky. References Valavanis A, Pangalu A, Tanaka M. Endovascular treatment of cerebral arteriovenous malformations with emphasis on the curative role of embolisation. Schweizer Arch fur Neurol und Psychiatr. 2004;155(7):341–347 Sekhar LN, Biswas A, Hallam D, Kim LJ, Douglas J, Ghodke B. Neuroendovascular management of tumors and vascular malformations of the head and neck. Neurosurg Clin N Am. 2009;20(4):453–485 Altschul D, Paramasivam S, Ortega-Gutierrez S, Fifi JT, Berenstein A. Safety and efficacy using a detachable tip microcatheter in the embolization of pediatric arteriovenous malformations. Child’s Nerv Syst. 2014;30(6):1099–1107 Chapot R, Stracke P, Velasco A, Nordmeyer H, Heddier M, Stauder M, Schooss P, Mosimann PJ. The pressure cooker technique for the treatment of brain AVMs. J Neuroradiol. 2014;41(1):87–91 Disclosures A. Biswas: None. M. Echt: None. D. Altschul: None. D. Gordon: None.