Balloon-assisted Onyx Embolization Research Articles

Dural arteriovenous fistula of the craniocervical junction along the first cervical nerve: A single-center experience and review of the literature

BackgroundDural arteriovenous fistulas (DAVFs) of the craniocervical junction (CCJ) are relative rare lesions. Most studies of DAVFs of the CCJ included the fistulas at the foramen magnum, first cervical (C1), and second cervical (C2) level. DAVFs of the CCJ along C1 spinal nerve are rare vascular lesions with distinctive features. Our aim is to review cases of DAVFs of the CCJ along C1 spinal nerve at our institution. MethodsFrom June 2008 and December 2021. We reviewed a consecutive series of intracranial and spinal DAVFs at our institution and collected all patients harboring DAVFs of the CCJ along C1 spinal nerve. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, treatment methods, and neurological outcome and complications after treatment. All image studies, including cranial computed tomography (CT) scan, cervical magnetic resonance imaging, CT angiography, and digital subtraction angiography (DSA) with rotational CT angiography were analyzed by experienced neuroradiologists. The authors also review of the literature of DAVFs of the C1 spinal nerve. ResultsThe authors identified 7 patients, including 5 men (71.4 %) and 2 women (28.6 %) with median age 54 years, range 48–72 years. Subarachnoid hemorrhage (SAH) occurred in 5 (71.4 %) patients, and progressive myelopathy in 2 (28.6 %). All fistulas except one received blood supply from the radiculomeningeal branch of the VA at C1 level. Venous aneurysms, being the source of bleeding, were detected in all fistulas with SAH. All patients except one were treated by surgical management. One fistula was treated by balloon-assisted Onyx embolization. Most patients had good neurological outcome following surgery. Complete obliteration of all fistulas treated by surgery was confirmed by follow-up DSA obtained 1 week after surgery. Two patients developed temporary pain and spasm of the trapezius muscle after the surgery. One patient resulted in poor neurological outcome and died due to sepsis and acute upper gastrointestinal bleeding one month after failed embolization. For patients with SAH, only one patient required ventriculoperitoneal shunt. ConclusionsDAVFs of the CCJ along the first spinal nerve are rare and a unique subtype of DAVFs at the CCJ. These fistulas account for 1.74 % of all intracranial and spinal DAVFs in the present study. SAH is the major manifestation of DAVFs at C1 spinal nerve that may be overlooked on routine initial DSA. Rotational CT angiography is useful for clarification of the angioarchitecture of these fistulas, including small feeding artery and venous varix. Surgical treatment by interruption of the intradural draining vein should be the treatment of choice for C1 spinal nerve DAVF

Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization

BackgroundAlthough not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles.Case presentationIn this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA).ConclusionsThe Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

Long-term follow-up of transarterial balloon-assisted Onyx embolization for endovascular treatment of dural arteriovenous fistulas: A single-institution case series and literature review

ObjectiveDural arteriovenous fistulas (DAVFs)—specifically, symptomatic DAVFs with cortical venous reflux—are aggressive lesions with a poor prognosis. Intra-arterial endovascular closure is considered the optional treatment for DAVFs and is currently performed at several international centers. However, long-term outcomes remain unknown. This study investigated the long-term efficacy and safety of transarterial balloon-assisted Onyx embolization in the treatment of DAVFs. MethodsA total of 14 consecutive patients who underwent endovascular treatment for DAVFs were treated by balloon-assisted Onyx embolization. Additionally, we retrospectively reviewed all cases reported in the literature and compared the outcomes of patients treated with single- vs dual-lumen microcatheters. ResultsThe patients at our institution were followed-up for 114.57 ± 33.52 months. Embolization was performed by balloon-assisted Onyx injection via a single feeding artery. Complete occlusion was achieved in 13 cases and partial occlusion in 1 case. At the final follow-up, all patients were functionally independent (Modified Rankin Scale score of 0–2), with no recurrence. In our review of 70 published cases of DAVFs that underwent endovascular treatment by balloon-assisted Onyx embolization, single- and dual-lumen balloon catheters were used in 33 and 37 patients, respectively. In the former group, there was complete or near-complete occlusion in 32 cases and partial occlusion in 1 case; and in the latter, there was complete or near-complete occlusion in 35 cases and partial occlusion in 2 cases. There were no deaths following endovascular treatment. ConclusionMeasurable and durable outcomes can be achieved by endovascular treatment of DAVFs with the transarterial balloon-assisted Onyx embolization technique, especially in cases with small, distal, and circuitous feeding arteries.

Transvenous Onyx embolization for dural arteriovenous fistula with concomitant transvenous balloon protection of the venous sinus.

The purpose of this study was to evaluate the technical efficacy and safety of transvenous Onyx embolization for dural arteriovenous fistulas (DAVFs) with concomitant transvenous balloon protection of the venous sinus when transarterial route failed or was not feasible. Between September 2010 and December 2016, thirty-six patients presenting with intracranial DAVFs underwent transvenous balloon-assisted Onyx embolization. The technical efficacy, treatment-related complications, and angiographic and clinical outcomes were reviewed from our prospectively maintained DAVF database. According to the Cognard Classification, 11 patients presented with clinically symptomatic Cognard type I; 11 cases with Cognard type IIa; 10 cases with Cognard type IIb; and 4 cases with Cognard type IIa+b. Complete angiographic occlusion of the DAVFs at the latest follow-up (mean 18 months after transvenous embolization) was achieved in 28 patients (77.8%), near-complete angiographic occlusion with minimal residual fistula in 5 patients (13.9%) and significant flow reduction of the DAVF in 2 patients (5.6%) and residual fistula for further treatment in 1 (2.8%) patient. Total clinical cure or remission of the pretreatment symptoms was achieved in 31 patients (31/36, 86.1%; 26 and 5 cases respectively). Affected venous sinus was preserved in 28 patients, intentionally occluded in 7 patients and gradually occluded in 1 patient. There were no immediate or long-term persistent complications after treatment. Transvenous Onyx embolization of dural arteriovenous fistulas with combined transvenous balloon protection of the venous sinus is safe and effective in achieving high occlusion rate, low embolization-related complications and satisfactory clinical outcomes.

Balloon-assisted Onyx Embolization in the Management of Complicated Dural Arterioevenous Fistula.

Dural arteriovenous fistula (dAVF) is an abnormal vascular communication between the meningeal artery and vein at the dura mater, with frequent recruitment of collateral arterial pedicles. In recent years, Onyx embolization has become the mainstay intervention for dAVF at various locations, although an unfavorable vascular anatomy often limits effective obliteration of the lesion. Balloon assistance may facilitate curable occlusion of the abnormal shunt with Onyx while preserving the patency of the affected sinus, even in complicated dAVFs. We retrospectively reviewed the clinical and angiographic findings of patients with dAVF treated endovascularly in our institution between September 2018 and August 2019. Based on the detailed analysis of individual angioarchitecture, we defined complicated dAVF as lesions for which a complete cure is considered difficult to achieve with simple transarterial Onyx embolization alone, primarily due to a high flow and/or diffuse shunt with or without drainage to the functioning but compromised sinus. We evaluated the preoperative symptoms, anatomical classification, endovascular procedure, radiologic results, and clinical outcomes of these patients. Five patients met our criteria, all of whom were treated with balloon-assisted Onyx embolization (two superior sagittal sinus dAVF, two transverse-sigmoid sinus dAVF, and one torcular dAVF). In four cases, Onyx was injected from a tiny branch of the middle meningeal artery under balloon occlusion of the collateral arteries or balloon devascularization of the competitive inflow. In three cases, balloon sinus protection was performed to prevent the inadvertent occlusion of the vital venous outflow with Onyx. In one case, for the complementary occlusion of the remnant shunt through the previously coiled but recanalized occipital artery, Onyx was injected from the wire lumen of a dual-lumen balloon catheter to avoid undesirable reflux. The angiographic results were an anatomical cure in four cases and near-complete occlusion in one case. No procedural complications were observed in any cases. The clinical outcome was a complete cure in four cases and improvement in one case. Our cases suggest that balloon devascularization can improve the unfavorable flow environment and simplify the vascular anatomy. Balloon sinus protection can support not only securing the patency of the normal venous outflow but also encourage aggressive intervention. Onyx injection via a dual-lumen balloon catheter can augment the controllability of embolization while preventing reflux. Each of these techniques can facilitate safe and effective Onyx embolization in the treatment of complicated dAVFs, and their combination may further expand the therapeutic horizon.

Transvenous balloon-assisted Onyx embolization of dural arteriovenous fistulas of hypoglossal canal.

This retrospective study summarized the technique aspects and effectiveness of transvenous balloon-assisted Onyx embolization treating selected dural arteriovenous fistulas of hypoglossal canal (HCDAVFs). Eight patients of HCDAVFs from January 2010 to December 2016 in a single institution were reviewed retrospectively. There were six males and two females aged from 30 to 69years (mean age, 52.8years). Eight patients presented with pulsatile tinnitus, four associated with ocular symptom, and one accompanied with tongue muscle atrophy. All lesions were with accessible venous approach from ipsilateral internal jugular vein. The microcatheter was positioned in the venous pouch from internal jugular vein; the remodeling balloon was advanced from internal jugular vein into inferior petrosal sinus. The balloon having 4mm in diameter and 15mm in length was inflated to temporarily block the antegrade venous drainage from fistulous pouch to internal jugular vein during the injection of Onyx. Approximately 1- to 2.1-ml Onyx-18 was used as the sole embolic material to obliterate the lesions. All lesions were occluded completely in a single-session embolization without procedural complications and postoperative new symptom. The follow-up period ranged from 6 to 13months. Preoperative ocular symptom and tinnitus were resolved completely in all patients. The follow-up angiograms of three patients demonstrated durable occlusion. Our experience in this small series of patients indicated transvenous balloon-assisted Onyx embolization was a feasible and effective option for treating selected HCDAVFs.

3:18 PM Abstract No. 103 Balloon-assisted Onyx embolization of high-flow peripheral arteriovenous malformations with dual-lumen coaxial balloon microcatheter: technical aspects and clinical results

The aim of this study was to demonstrate our experience in balloon-assisted Onyx (ethylene vinyl alcohol copolymer) embolization of high-flow peripheral arteriovenous malformations (AVMs) using dual-lumen coaxial balloon microcatheter technique, which does not necessitate a plug formation around the catheter that is required to allow antegrade flow of Onyx while preventing reflux and non-target embolization. This study expands the technique with its utilization on types of AVMs not described previously. Three patients with peripheral high-flow AVMs treated with balloon-assisted Onyx embolization using dual-lumen coaxial balloon microcatheter were retrospectively analyzed. AVMs were located in the kidney, pelvis, and chest wall. One patient required two sessions of Onyx embolization treatment. A total of 4 sessions were performed with Onyx 18 and/or Onyx 34 using Scepter XC occlusion balloon catheter. Imaging and clinical follow-ups were performed for all patients. Technical success was achieved in all patients. Complete devascularization was obtained in two patients with renal and pelvic AVMs with one treatment, while the patient with chest wall AVM required two sessions, which resulted in complete devascularization. There was no evidence of excessive reflux of Onyx or entrapment of the microcatheter. Non-target Onyx embolization or microcatheter fracture was not observed. After the final treatment, all patients were free of symptoms on clinical follow-up, and there was no evidence of recurrence identified on follow-up imaging. From our single-institutional experience, the technique using dual-lumen coaxial balloon microcatheter for balloon-assisted Onyx embolization appears to be safe and effective in treating high-flow peripheral AVMs, while allowing more precise injection of Onyx with the capability to reduce the risks associated with reflux of Onyx.

An Onyx tunnel: reconstructive transvenous balloon-assisted Onyx embolization for dural arteriovenous fistula of the transverse-sigmoid sinus.

Transvenous embolization is an effective method for treating dural arteriovenous fistulas (DAVFs) of the transverse-sigmoid sinus (TSS). However, in cases of complicated DAVFs, it is difficult to preserve the patency of the dural sinus. The authors describe the technical details of a new reconstructive technique using transvenous balloon-assisted Onyx embolization as another treatment option in a patient with an extensive and complex DAVF of the left TSS. A microcatheter and compliant balloon catheter were navigated into the left internal jugular vein and placed at the distal end of the DAVF in the transverse sinus. The microcatheter was placed between the vessel wall of the TSS and the balloon. After the balloon was fully inflated, Onyx-18 was injected at the periphery of the balloon in a slow, controlled, progressive, stepwise manner; the balloon and microcatheter were simultaneously withdrawn toward the sigmoid sinus, with Onyx encompassing the entirety of the complex DAVF. The Onyx refluxed into multiple arterial feeders in a distal-to-proximal step-by-step manner, ultimately resulting in an Onyx tunnel. The final angiography study revealed complete obliteration of the DAVF and patency of the TSS. The Onyx tunnel, or reconstructive transvenous balloon-assisted Onyx embolization technique, may be an effective treatment option for large, complex DAVFs of the TSS. This technique may provide another option to facilitate the complete obliteration of the DAVF while preserving the functional sinus.

Treatment of Superior Sagittal Sinus Dural Arteriovenous Fistula by Transarterial Multiple Balloon-assisted Onyx Embolization: A Case Report

Treatment of Superior Sagittal Sinus Dural Arteriovenous Fistula by Transarterial Multiple Balloon-assisted Onyx Embolization: A Case Report

Balloon-assisted endovascular treatment of intracranial dural arteriovenous fistulas

Objective To report experiences in balloon-assisted endovascular Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs).Methods Clinical records of 6 DAVFs patients treated with balloon-assisted endovascular Onyx embolization were retrospectively collected to analyze their presenting symptoms,angiographic features,endovascular treatments,and clinical outcomes.Results Four patients were presented with cortical venous reflux.Five patients underwent transarterial and one patient underwent transvenous Onyx embolization adjunct to transarterial balloon protection.The balloons were use to protect ICA in 4 patients,to protect VA in 1 patient,and to prevent Onyx reflux in MMA in 1patient.Angiograms obtained immediately after embolization demonstrated complete transarterial obliteration of the fistula in 4 patients and partial occlusion in 2.One patient had Onyx embolization-relatted complication of transient hemi-facial hypoesthesia.Conclusions Balloon adjunct to Onyx embolization can provide protection of the intracranial artery in the treatment of intracranial DAVFs with double blood supply from intracranial and extracranial arteries.Balloons could prevent Onyx reflux and decrease the flow rate of fistula when placed into the blood supply artery. Key words: Dural arteriovenous fistula; Embolization ; Balloon ; Onyx

Endovascular Balloon-Assisted Embolization of Intracranial and Cervical Arteriovenous Malformations Using Dual-Lumen Coaxial Balloon Microcatheters and Onyx

Abstract BACKGROUND: Ethylene vinyl alcohol copolymer (Onyx) is widely used for the embolization of arteriovenous malformations (AVMs) of the brain, head, and neck. Balloon-assisted Onyx embolization may provide additional unique advantages in the treatment of AVMs in comparison with traditional catheter-based techniques. OBJECTIVE: To report our initial experience in performing balloon-assisted AVM embolization for brain and neck AVMs with the use of the new Scepter-C and Scepter-XC coaxial dual-lumen balloon microcatheters. METHODS: Balloon-assisted transarterial embolization was performed in a series of 7 patients with AVMs (4 with brain AVMs, 1 with a dural arteriovenous fistula, and 2 with neck AVMs) by using Onyx delivered through the lumen of Scepter-C or Scepter XC coaxial balloon microcatheters. Following the initial balloon-catheter navigation into a feeding artery and the subsequent inflation of the balloon, the embolization was performed by using Onyx 18, Onyx 34, or both. RESULTS: A total of 12 embolization sessions were performed via 17 arterial feeders in these 7 patients. In 1 patient, there was an arterial perforation from the inflation of the balloon; in all others, the embolization goals were successfully achieved with no adverse events. CONCLUSION: The balloon microcatheters showed excellent navigability, and there were no problems with retrieval or with the repeated inflation and deflation of the balloons. A proximal Onyx plug, which is crucial in many AVM embolizations, was not necessary with this technique. Additionally, fluoroscopy and procedural times seemed lower with this technique compared with conventional embolization methods.

Abstract TMP120: Endovascular Balloon-Assisted Embolization of Intracranial Arteriovenous Malformations Using Dual Lumen Co-Axial Balloon Microcatheters and Onyx: Initial Experience.

Background: Ethylene Vinyl alcohol co-polymer (Onyx) is widely used for embolization of intracranial arteriovenous malformations. Traditional catheter based techniques for Onyx infiltration may be associated with reflux of Onyx resulting in cathteter retention, vessel rupture or reflux into en-passage arteries. Balloon assisted Onyx embolization may eliminate some of these problems encountered with traditional catheter based techniques. Herein, we report our initial experience in performing balloon assisted AVM embolization for brain AVMs and dural AVFs using the new Scepter-C and Scepter-XC co- axial dual lumen balloon microcatheters. Methods: Balloon-assisted trans-arterial embolization was carried out in a series of six patients (5 with brain AVMs, one with a dural AVF ) using Onyx delivered through the lumen of Scepter-C or Scepter XC co-axial balloon microcatheters. Following initial balloon-catheter navigation into a feeding artery as close to the nidus of the malformation as possible, and subsequent balloon inflation, embolization was performed using Onyx 18 or Onyx 34 or both. The balloon was delated and removed once adequate embolization had been achieved. Results: A total of ten embolization sessions were performed via fifteen arterial feeders in these five patients. In one out of fifteen vessels (7%), there was a quickly controlled arterial perforation from balloon inflation, in all others embolization goals for each session were successfully achieved with no adverse events. Conclusion: We found that the balloon microcatheters showed excellent navigability and there were no problems with retrieval or repeated inflation and deflation of the balloons. Using this technique, we were able to avoid the need for formation of a proximal Onyx plug and its associated risks. Additionally, fluoroscopy and procedural times seemed lower with this technique compared to conventional embolization methods.

Onyx Embolization of Dural Arteriovenous Fistula, using Scepter C Balloon Catheter: a Case Report

We report our experience using Onyx for embolization of dural arteriovenous fistula (DAVF) under dual lumen balloon catheter flow arrest. Transfemoral cerebral angiography revealed a superior sagittal sinus (SSS) DAVF that was supplied via multiple branches of the external carotid arteries, the right anterior cerebral arteries, and the meningeal branches of the internal carotid artery. There was no anterograde venous drainage through the SSS, and venous drainage was almost retrograde through the medullary and cortical veins. Under general anesthesia, a transvenous approach was utilized to place the microcatheter close to the fistula site. After intravenous embolization with various coils, DAVF was partially occluded; Balloon catheter gained access to the DAVF via the right middle meningeal artery. We injected Onyx through the Scepter C catheter, after which DAVF was nearly completely occluded. Balloon-assisted Onyx embolization is a feasible and effective approach for the management of DAVF.