Use Of Liquid Embolic Agents Research Articles

Onyx© Embolization of Dural Arteriovenous Fistulae at the Cranio-Cervical Junction (P8-5.024)

<h3>Objective:</h3> To report two cases of CRC fistula treated successfully with endovascular embolization with Onyx©. <h3>Background:</h3> Dural arteriovenous fistula (dAVF) are rare vascular malformations; a rare subset of this group are dAVFs located at the cranio-cervical junction. Subarachnoid hemorrhage (SAH) is one of the possible neurological complications of cranio-cervical (CRC) fistula rupture. Treatment options include radiosurgery, endovascular embolization and/or open surgery. The use of liquid embolic agent is a reasonable option for endovascular treatment. <h3>Design/Methods:</h3> A single institution retrospective case report identified two case of cranio-cervical junction (CRC) fistulae that were treated successfully with Onyx© embolization. <h3>Results:</h3> Two patients were identified to have cranio-cervical junction DAVF in which one patient presented with SAH, and the 2^nd patient presented with bulbar symptoms due to rapidly worsening edema in the brainstem. Both fistulas were supplied from the vertebral artery; one at the level of Dural ring of the vertebral artery and the other at the jugular foramen level which was also supplied by ascending pharyngeal artery. Onyx© embolization was the treatment of choice in both cases. The Onyx© embolization resulted in 80% reduction of the fistula nidus in the first case, and complete occlusion of the fistula in the second and the third case. The 6 months follow-up revealed complete occlusion of both fistulas with complete neurological recovery <h3>Conclusions:</h3> This case series suggests that the treatment of CRC fistulae with Onyx© embolization is efficacious with good clinical outcomes. <b>Disclosure:</b> Dr. Gharaibeh has nothing to disclose. Dr. Al-Chalabi has nothing to disclose. Dr. Oliver has nothing to disclose. Dr. Jumaa has nothing to disclose.

Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described. We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent. After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed. FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.

Prostatic artery occlusion versus prostatic artery embolisation for the management of benign prostatic hyperplasia: early results in a canine model.

To compare the technical efficacy and safety between prostatic artery occlusion (PAO) with ethylene vinyl alcohol copolymer (EVOH) and prostatic artery embolizsation (PAE) with microspheres in a canine model. 17 adult male beagles underwent PAO (n = 7) with Onyx-18 or PAE (n = 10) with microspheres (300-500 µm). To evaluate the primary outcomes (technical efficacy and safety), MRI evaluations were performed immediately before and 1 week, 2 weeks, and 1 month after procedures to document prostate volume (PV); and all dogs were inspected for procedure-related complications during 1 month follow-up. The secondary outcomes included the prostate ischaemia size detected by MRI and recanalisation of prostatic artery by follow-up angiography. Differences between groups were statistically analysed. Both procedures were bilaterally successful in all animals. Compared with PAE, the mean fluoroscopy time (23.80 vs 36.24 min, p = 0.014) and radiation dose (68.19 vs 125.26 mGy, p = 0.003) were significantly less in PAO procedure. The mean percentage of PV change significantly decreased in both groups at 2 weeks (30.71% vs 37.89%) and 1 month (56.41% %vs 55.56%) after PAO and PAE respectively), without significant differences between groups at either time point. No major complications were observed except one animal after PAO with transient haematuria and acute urinary retention. The mean prostate ischaemia induced by PAO was significant greater compared with PAE at 1 week (43.44% vs 18.91%, p=0.001). PAO with EVOH is technically feasible and with comparable efficacy and safety with PAE. There are possible benefits to PAO over PAE. A new technical modification of the PAE consisting of the use of liquid embolic agent to occlude the prostatic artery trunk and its branches has been developed in pre-clinical study, showing to be an effective and safe procedure which can induce a significant prostate shrinkage for the management of symptomatic benign prostatic hyperplasia in patients. In addition, the findings have showed a similar therapeutic effect comparable with the conventional PAE using microspheres.

Single institution early clinical experience with the Scepter Mini balloon catheter.

The use of liquid embolic agents in the endovascular treatment of dural arteriovenous (dAVFs) fistulas and brain arteriovenous malformations (AVMs) has become common practice. The use of dual lumen balloon microcatheters has greatly improved the efficacy of liquid embolization. The purpose of this series is to discuss our early experience with the Scepter Mini dual lumen balloon microcatheter. A retrospective chart review was performed of all patients who underwent embolization with the Scepter Mini dual lumen balloon at a single institution. Technical details and procedural complications were recorded for each case. In total, 10 Scepter Mini dual lumen balloon microcatheters were used in nine patients. All patients except two were treated for AVMs. Technical success was achieved in all but one case where one balloon had to be discarded due to precipitation of the tantalum powder. Average vessel diameter where the balloon was inflated was 1.1 mm (0.8-2.4 mm). It provided flow arrest in 100% of cases with no cases of reflux of embolic material. Balloon "jump back" was found to occur in 44.4% (4/9) of cases. Seven out of nine cases used Onyx, and two cases used n-butyl cyanoacrylate. The Scepter Mini is a new dual lumen balloon ideal for distal access and can be used for embolization with liquid embolic agents with a high degree of technical success. Its great benefit is the immediate and safe flow arrest of distal vasculature upon balloon inflation. One important consideration for effective embolization is early identification of balloon jump back.

Pial arteriovenous fistula: A clinical and neuro-interventional experience of outcomes in a rare entity

Purpose:Pial arteriovenous fistulae (PAVF) are rare intracranial vascular malformations, predominantly seen in children and distinct from arteriovenous malformations and dural arteriovenous fistulae. PAVF often leads to high morbidity and mortality. The aim of our study was to describe the clinical features and endovascular management of PAVF at various intracranial locations; to analyze the use of liquid embolic agents and coils alone or in combination in the treatment of PAVF and to analyze the outcome of embolization.Materials and Methods:Retrospective review of diagnostic angiography and neurointerventional database of our institution identified a cohort of 15 patients with non-galenic PAVF from 2008 to 2014 out of 6750 patients. Fourteen patients were treated endovascularly with coils and liquid embolic materials in combination or alone. Patients were followed up for evaluation of prognosis.Results:Age of the patients ranged from 3 to 37 years. Most patients were male and most common presentation was headache followed by seizure. Most common location of fistula was frontal lobe. The most common type was single artery single hole fistula with venous varix. Satisfactory obliteration was seen in all cases. One patient developed intraparenchymal hematoma on the first post procedural day and outcome was poor.Conclusions:PAVF are rare intracranial vascular malformations which can effectively be managed endovascularly with liquid embolic, coils alone, or in combination. Complete occlusion of the fistula can be achieved in most cases in a single sitting with a reasonable morbidity related to the procedure, compared with the natural history of this disease.

Effectiveness of Intra-Arterial Aneurysm Sac Embolization for Type Ia Endoleak after Endovascular Aneurysm Repair

PurposeTo evaluate the effectiveness and durability of intra-arterial aneurysm sac embolization for the treatment of type Ia endoleak after endovascular aneurysm repair (EVAR). Materials and MethodsFrom February 2011 to December 2016, 22 patients underwent embolization of a type Ia endoleak after EVAR. Four patients (18%) were treated during the index EVAR and 18 (82%) in follow-up. Five patients (23%) were treated urgently and 17 (77%) electively. The embolization was performed with the use of liquid embolic agent, coils, and/or plugs. Adjunctive neck procedures were performed in 55% (n = 12) of the patients. The primary endpoint of this study was freedom from sac enlargement. Key secondary endpoints were technical success and freedom from endoleak-related reinterventions. ResultsTechnical success was 100%. The 30-day mortality was 5% (n = 1; acute coronary syndrome). At a mean follow-up of 15.4 months (range 0.1–65.4) the freedom from sac enlargement rate was 76% (16 out of 21). Reintervention-free survival rates at 6, 12, and 24 months were 80%, 68% and 68%, respectively. ConclusionsIn patients with persistent type Ia endoleak the embolization of the aneurysm sac with or without adjunctive neck procedures can be safely performed, leading to acceptable clinical and radiologic outcomes.

N-butyl cyanoacrylate embolotherapy: techniques, complications, and management.

The purpose of this article is to describe acute complications associated with adhesive cyanoacrylate deposition in the peripheral circulation and their management. Despite best efforts, n-butyl cyanoacrylate glue embolization is inherently unpredictable and complications do occur. An understanding of preparation techniques that minimize adverse event rates and the technical skillset required to manage complications are necessary for the safe and efficient use of liquid embolic agents.

5:18 PM, Abstract No. 85 - Use of liquid embolic agents in the treatment of aortopulmonary collaterals in pediatric patients with congenital heart disease

Purpose: To assess the technique and clinical outcomes for pre-operative n-butyl cyanoacrylate glue embolization of pediatric head and neck venous malformations. Materials and Methods: A retrospective analysis was conducted over a 9-year period at a tertiary care pediatric hospital to identify cases of head and neck venous malformations that were embolized with n-BCA prior to resection. 24 embolizations were performed in 22 patients. 7 patients were male, and mean age was 12.4 years (range 2-25). Primary clinical symptoms included pain (65%), swelling (61%), cosmetic disfigurement (87%), and bleeding (9%). 41.7% of patients had received prior intervention including surgical resection, laser ablation therapy, or sclerotherapy. Sites treated included cheek (n1⁄47), perimandibular regions (n1⁄45), lip (n1⁄44), neck (n1⁄44), tongue (n1⁄43), periorbital regions (n1⁄42), and temporalis muscle (n1⁄41). Mean volume of n-BCA used was 2.69mL; all embolizations were performed through direct percutaneous punctures via 21 or 23 gauge needles, using a range of 1:1 to 1:5 dilutions of n-BCA in ethiodized oil. Prior to injecting the embolization mixture, biplane digital subtraction venography was performed. Same-day pre-operative glue embolization and surgical resection took place for 21 out of 22 patients. Results: All patients were transported to the OR under stable conditions. Technical success rates for both embolization and resection were 100%. One patient had clinically insignificant embolization of a small amount of glue to a subsegmental pulmonary artery. No other complications were recorded. Adjunctive sclerotherapy or further glue embolization with resection was performed in 3 out of 22 patients who had large lesions. Average hospital stay was 1.5 days, with follow up scheduled for 1 week, 1 month, and 6 months. Follow-up indicated successful alleviation of primary symptoms for all patients based on clinical findings. Conclusion: Pre-operative n-BCA glue embolization of pediatric head and neck venous malformations is a safe and effective treatment option for these lesions. Advantages include the ability to achieve a more complete resection with diminished surgical blood loss. Technical and clinical success rates in this series were 100%.

In Vitro Study of Photocurable Embolization Agent for Cerebral Aneurysms

The use of liquid embolic agents for the endovascular treatment of cerebral aneurysms has been reported in the neurosurgical literature. A major limitation of these agents is their relatively poor control of hardening ability. In this study, the technical feasibility of a novel gelatin-based photocurable liquid agent for embolization of cerebral aneurysms was evaluated using an experimental aneurysm model. The embolic agent used in this study was an aqueous mixture of photocurable gelatin (gelatin partially derivatized with eosin; 20 wt%; eosin content: 2.8 per gelatin molecule) and polyamine (a polymer of N,N -dimethylaminopropylacrylamide; 5 wt%). Because of its appropriate viscosity at 37 ⁰ C (206 ± 45 mPa•s), the agent could be delivered into the sac of a glass aneurysm model (internal diameter: 3 mm at parent artery part; 5 mm at aneurysm part) by using through a 6 French (Fr)-delivery catheter under the inflation of a balloon catheter at the neck of the aneurysmal sac. After photo irradiation for 40 seconds, the neck of the aneurysm was capped with hydrogel converted from the agent (100%, n=5). Because the colored water was distributed evenly in only a parent tube, complete embolization was observed. Thus, this photocurable agent has potential to be used for the embolization of cerebral aneurysms.

006 Onyx embolization for treatment of traumatic and mycotic distal aneurysms involving the cerebral and cranial vasculature

Background and Purpose: Endovascular intervention is the firstline treatment of traumatic and mycotic distal aneurysms. However, intraprocedural rupture remains an endangering event given the extremely fragile wall of these lesions....

Endovascular Treatment of Large and Giant Intracranial Aneurysms with Use of Mixture Different Embolic Materials

Intracranial aneurysm is a common condition but with a high mortality rate when rupture occurs. The treatment of ruptured or unruptured ICA, especially with an endovascular approach, has been evolving rapidly. The current generally accepted opinion suggests that endovascular embolization is an effective technique for preventing the recurrence of aneurysm rupture, but the rebleeding rate after endovascular embolization is found to be higher than that after surgical clipping. In addition, long-term follow-up data are required for the evaluation of the effectiveness of endovascular treatment in unruptured ICA. This review presents the selection of different treatment approaches, and in particular, the advances in endovascular embolization in the treatment of ICA, including mixture of variety of embolic materials such as coils, stents, ONYX and acrylates. The use of liquid embolic agents for embolization of cerebral aneurysms has been reported in the neurosurgical literature. The most important limitation of this technique is the relatively poor control of migration of the liquid embolic agent into the parent artery. We performed an 7 aneurysm embolisations study using a liquid embolic agent and different protective devices and embolic materials to evaluate the safety and technical feasibility of this endovascular technique. Endovascular treatment of cerebral aneurysms with detachable coils has now been proven to be a superior alternative to open microsurgery in terms of disability-free survival 1 year following treatment. Despite this, recurrence due to recanalization of these aneurysms in 10-20% of patients after coiling is still the main drawback of the endovascular technique. In the last 5 years, access devices and endovascular tools based on new concepts, materials and endovascular reconstruction techniques that go beyond simply coiling have been described for cerebral aneurysm treatment, especially for more complicated broad-necked, fusiform and large/giant aneurysms.

Onyx in an experimental aneurysm model: histological and angiographic results

The use of liquid embolic agents for endovascular treatment of cerebral aneurysms is evolving. The authors' aim was to evaluate the use of Onyx HD-500 in an experimental aneurysm model and to obtain histological and angiographic long-term results. Ten aneurysms were created using an elastase model in rabbits. The aneurysms were embolized using Onyx in combination with an inflated balloon. One animal died 1 day after embolization. The animals were divided into 2 different groups. The animals in the first group (4 rabbits) were killed at 3 months and those in the second group (5 rabbits) were killed at 6 months after embolization. A venous control angiogram was obtained, and the aneurysms were examined histologically. In both groups control angiograms demonstrated that all aneurysms were completely occluded. There were no signs of recanalization. Migration of Onyx was seen in 4 animals, leading to the death of 1. Histological examination not only proved the aneurysms to be occluded but also demonstrated a thin layer of endothelium at the neck of the aneurysm. The histological result was identical in both groups. This is the first study reporting the formation of a neointima over the neck of aneurysms embolized with Onyx in a rabbit model. Although the technique is challenging and migration of the liquid embolic agent cannot always be prevented, Onyx has a great potential to achieve a durable occlusion of aneurysms.