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Smith ER. Pediatric Cerebral Vascular Malformations : Current and Future Perspectives. J Korean Neurosurg Soc 2024; 67:326-332. [PMID: 38409785 PMCID: PMC11079569 DOI: 10.3340/jkns.2024.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/06/2024] [Accepted: 02/25/2024] [Indexed: 02/28/2024] Open
Abstract
Intracranial vascular malformations typically encountered by pediatric neurosurgeons include arteriovenous malformations, vein of Galen malformations and cavernous malformations. While these remain amongst some of the most challenging lesions faced by patients and caregivers, the past decade has produced marked advances in the understanding of the pathophysiology of these conditions, with concomitant innovations in treatment. This article will highlight present and future perspectives relevant to these diseases, with a focus on an emerging approach utilizing disease-specific mutations to develop a novel taxonomy for these conditions.
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Affiliation(s)
- Edward R. Smith
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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2
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Salem MM, Kelmer P, Sioutas GS, Ostmeier S, Hoang A, Cortez G, El Naamani K, Abbas R, Hanel R, Tanweer O, Srinivasan VM, Jabbour P, Kan P, Jankowitz BT, Heit JJ, Burkhardt JK. Multicenter US clinical experience with the Scepter Mini balloon catheter. Interv Neuroradiol 2024:15910199241246135. [PMID: 38613371 DOI: 10.1177/15910199241246135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
INTRODUCTION Distal navigability and imprecise delivery of embolic agents are two limitations encountered during liquid embolization of cerebrospinal lesions. The dual-lumen Scepter Mini balloon (SMB) microcatheter was introduced to overcome these conventional microcatheters' limitations with few small single-center reports suggesting favorable results. METHODS A series of consecutive patients undergoing SMB-assisted endovascular embolization were extracted from prospectively maintained registries in seven North-American centers (November 2019 to September 2022). RESULTS Fifty-four patients undergoing 55 embolization procedures utilizing SMB were included (median age 58.5; 48.1% females). Cranial dural arteriovenous fistula embolization was the most common indication (54.5%) followed by cranial arteriovenous malformation (27.3%). Staged/pre-operative embolization was done in 36.4% of cases; and 83.6% of procedures using Onyx-18. Most procedures utilized a transarterial approach (89.1%), and SMB-induced arterial-flow arrest concurrently with transvenous embolization was used in 10.9% of procedures. Femoral access/triaxial setups were utilized in the majority of procedures (65.5% and 60%, respectively). The median vessel diameter where the balloon was inflated of 1.8 mm, with a median of 1.5 cc of injected embolic material per procedure. Technical failures occurred in 5.5% of cases requiring aborting/replacement with other devices without clinical sequelae in any of the patients, with SMB-related procedural complications of 3.6% without clinical sequelae. Radiographic imaging follow-up was available in 76.9% of the patients (median follow-up 3.8 months), with complete occlusion (100%) or >50% occlusion in 92.5% of the cases, and unplanned retreatments in 1.8%. CONCLUSION The SMB microcatheter is a useful new adjunctive device for balloon-assisted embolization of cerebrospinal lesions with a high technical success rate, favorable outcomes, and a reasonable safety profile.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Paz Kelmer
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Sophie Ostmeier
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
| | - Alex Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Gustavo Cortez
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Ricardo Hanel
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch Galveston, Galveston, TX, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Jeremy J Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
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Tong X, Ye M, Li J, Hu P, Hong T, Zhang P, Zhang H. Transvenous Onyx embolization for dural arteriovenous fistula with concomitant transvenous balloon protection of the venous sinus. J Neurosurg Sci 2024; 68:89-100. [PMID: 32347677 DOI: 10.23736/s0390-5616.20.04937-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing, China -
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Clarençon F, Papagiannaki C, Saleme S, Rouchaud A, Shotar E, Rius E, Burel J, Boch AL, Sourour NA, Mounayer C. Balloon Pressure Technique with the Scepter Mini Balloon as Part of the Endovascular Strategy for Brain Arteriovenous Malformations Embolization : Preliminary Multicenter Experience. Clin Neuroradiol 2023; 33:1055-1065. [PMID: 37401950 DOI: 10.1007/s00062-023-01309-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/16/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND The balloon pressure technique (BPT) is an alternative to the pressure cooker technique. A dual lumen balloon (DLB) is used to inject the liquid embolic agent through the working lumen while the balloon is inflated. The purpose of our study was to report our early experience using the Scepter Mini dual lumen balloons for BPT in brain arteriovenous malformation (bAVM) embolization. MATERIAL AND METHODS Consecutive patients treated from July 2020 to July 2021 in 3 tertiary centers using the BPT with low-profile dual lumen balloons (Scepter Mini, Microvention, Tustin, CA, USA) by endovascular means for bAVMs were retrospectively reviewed. Patient demographics and bAVM angio-architectural features were collected. The feasibility of Scepter Mini balloon navigation close to the nidus was evaluated. Technical as well as clinical (ischemic and/or hemorrhagic) complications were also systematically assessed. The occlusion rate was evaluated on follow-up DSA. RESULTS A total of 19 patients (10 females; mean age = 38.2 years) consecutively treated for a bAVM (8 ruptured/11 unruptured) using the BPT with a Scepter Mini through 23 embolization sessions were included in our series. Navigation of the Scepter Mini was feasible in all cases. Of the patients 3 (16%) had procedure-related ischemic stroke and 2 patients (10.5%) had late hemorrhages. None of these complications led to severe permanent sequela. Complete occlusion of bAVM embolized with intention to cure was recorded in 11/13 cases (84.6%). CONCLUSION The BPT using low-profile dual lumen balloons is feasible and seems safe for embolization of bAVMs. It may help to reach high occlusion rates, especially when performed in the intent to cure by embolization only.
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Affiliation(s)
- Frédéric Clarençon
- Sorbonne University, Paris, France.
- GRC BioFast, Sorbonne University, Paris, France.
| | | | - Suzanna Saleme
- Department of Neuroradiology, Limoges University Hospital, Limoges, France
| | - Aymeric Rouchaud
- Department of Neuroradiology, Limoges University Hospital, Limoges, France
- University of Limoges, Limoges, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Bd de l'Hôpital, 75013, Paris, France
| | - Emily Rius
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Bd de l'Hôpital, 75013, Paris, France
| | - Julien Burel
- Department of Radiology, Rouen University Hospital, Rouen, France
| | - Anne-Laure Boch
- Department of Neurosurgery, APHP-Sorbonne University, Paris, France
| | - Nader-Antoine Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Bd de l'Hôpital, 75013, Paris, France
| | - Charbel Mounayer
- Department of Neuroradiology, Limoges University Hospital, Limoges, France
- University of Limoges, Limoges, France
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See AP, Smith ER. Evolution of clinical and translational advances in the management of pediatric arteriovenous malformations. Childs Nerv Syst 2023; 39:2807-2818. [PMID: 37462811 DOI: 10.1007/s00381-023-06077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 10/29/2023]
Abstract
Arteriovenous malformations (AVMs) represent one of the most challenging diagnoses in pediatric neurosurgery. Until recently, the majority of AVMs was only identified after hemorrhage and primarily treated with surgery. However, recent advances in a wide range of fields-imaging, surgery, interventional radiology, radiation therapy, and molecular biology-have profoundly advanced the understanding and therapy of these complex lesions. Here we review the progress made in pediatric AVMs with a specific focus on innovations relevant to clinical care.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA.
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Matsoukas S, Siddiqui N, Scaggiante J, Bageac DV, Shigematsu T, DeLeacy R, Mocco J, Majidi S, Kellner CP, Fifi JT. Safety and efficacy of dual lumen balloon catheters for the Treatment of cerebral vascular malformations: A systematic review, pooled analysis, and meta-analysis. Neuroradiol J 2023; 36:379-387. [PMID: 35738884 PMCID: PMC10588609 DOI: 10.1177/19714009221111089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is little evidence in scientific literature assessing the safety and efficacy of dual-lumen balloon catheters (DLBCs) and their performance compared to single-lumen catheters (SLCs). METHODS In this PROSPERO-registered, PRISMA-compliant systematic review, we identified all MEDLINE and EMBASE single-arm (DLBCs) and double-arm (DLBCs vs SLCs) cohorts where DLBCs were used for the treatment of cerebral arteriovenous malformations (AVMs) or dural arteriovenous fistulas (dAVFs). Immediate angiographic outcome, vascular complications, technical failures, reflux episodes and entrapment were the primary outcomes. A meta-analysis of the double-arm studies summarized the primary outcomes of total procedural time and immediate angiographic outcome. RESULTS The authors identified 18 studies encompassing 209 treated lesions with reported outcomes. Complete occlusion was achieved in 108/132 treated dAVFs (81.8%, 95% CI: [74-87.8%]) and in 45/77 treated AVMs (58.4%, [46.7-69.4%]). The proportion of completely occluded dAVFs was statistically significantly higher than that of AVMs, p < .001. There were eight reported vascular complications (3.8%, [1.8-7.7%]), five technical failures (2.4%, [0.9-5.8%]), 14 reflux events (6.7%, [3.9-11.2%]), two entrapment events (1%, [0.2-3.8%]) and 0 deaths (mortality rate 0%, [0-2.3%]). In a meta-analysis for the treatment of dAVFs, the total procedural time was significantly less for DLBCs compared to SLCs (64.9 vs 125.7 min, p < .0001). The odds of complete immediate occlusion were significantly higher with DLBCs compared to SLCs (odds ratio (OR) 4.6, [1.5-14.3], p = .008). CONCLUSION Dual-lumen balloon catheters are safe and effective for the embolization of cerebral AVMs and dAVFs and can achieve faster and potentially superior results compared to SLCs. REGISTRATION-URL https://www.crd.york.ac.uk/prospero/ Unique Identifier: CRD42021269096.
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Affiliation(s)
- Stavros Matsoukas
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Neha Siddiqui
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Jacopo Scaggiante
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Devin V Bageac
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | | | - Reade DeLeacy
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Shahram Majidi
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | | | - Johanna T Fifi
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
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Cekirge HS, Saatci I. Republished: Multiplug flow control technique as a novel transarterial curative approach for the endovascular treatment of cerebrovascular malformations. J Neurointerv Surg 2023; 15:e4. [PMID: 34108264 DOI: 10.1136/neurintsurg-2021-017418.rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 11/03/2022]
Abstract
Herein, we describe the use of a novel multiplug flow control technique for the curative transarterial embolisation of cerebrovascular malformations using liquid embolic agents (LEAs). The idea behind the use of this technique is to substantially control or arrest flow during LEA injection, with multiple plugs simultaneously formed from microcatheters that are placed within all or multiple feeders, so that the penetration of LEAs is facilitated, with flow control decreasing the washout of a malformation. This technique enables the complete occlusion of a vascular malformation in a shorter injection time than that in other methods because penetration is achieved faster. Details of this technique have been described in the treatment of two cases: one case of unruptured temporal arteriovenous malformation and in the other with a falcotentorial dural arteriovenous fistula, in which the vascular malformations were successfully occluded with transarterial embolisation.
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Affiliation(s)
- H Saruhan Cekirge
- Radiology Department, Private Koru Hospital, Ankara, Turkey .,Independent Researcher, Ankara, Turkey
| | - Isil Saatci
- Radiology Department, Private Koru Hospital, Ankara, Turkey
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8
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Matsoukas S, Rossitto CP, Berenstein A, Fifi JT. Infantile dural sinus malformation: curative embolization in two stages with the Scepter mini balloon microcatheter. J Neurointerv Surg 2023; 15:97-98. [PMID: 35428741 DOI: 10.1136/neurintsurg-2021-018608] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/06/2022] [Indexed: 12/16/2022]
Abstract
Endovascular embolization is the mainstay for treatment of infantile dural sinus malformations.1 2 Distal access and flow control are limiting factors in controlled embolization.3-6 The Scepter mini catheter (Microvention, Aliso Viejo, California, USA) is a low-profile, dual-lumen balloon microcatheter designed to provide navigability in small-caliber, tortuous intracranial vessels. In this technical video, we demonstrate the staged embolization of a dural sinus malformation with multiple arteriovenous fistulae using the Scepter mini catheter (video 1). In the newborn patient, embolizations were performed through the parietal branches of the left and right middle meningeal arteries. The catheter easily navigated into the small feeding arteries. No neurological complications occurred due to the procedures. Post-embolization injections demonstrated significant flow reduction into the malformation. Three-month follow-up angiography illustrated resolution of the previously dilated left transverse sinus. Complete obliteration of the dural sinus malformation was achieved in the newborn patient. neurintsurg;15/1/97/V1F1V1Video 1Curative embolization in two stages with the Scepter mini balloon microcatheter. ΑP, anteroposterior; CCA, common carotid artery.
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Affiliation(s)
- Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Schmidt VF, Masthoff M, Vielsmeier V, Seebauer CT, Cangir Ö, Meyer L, Mükke A, Lang W, Schmid A, Sporns PB, Brill R, Wohlgemuth WA, da Silva NPB, Seidensticker M, Schinner R, Küppers J, Häberle B, Haubner F, Ricke J, Zenker M, Kimm MA, Wildgruber M. Clinical Outcome and Quality of Life of Multimodal Treatment of Extracranial Arteriovenous Malformations: The APOLLON Study Protocol. Cardiovasc Intervent Radiol 2023; 46:142-151. [PMID: 36261507 PMCID: PMC9810564 DOI: 10.1007/s00270-022-03296-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/30/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Arteriovenous malformations (AVMs) as rare diseases are diagnostically and therapeutically challenging. Due to the limited evidence regarding treatment outcome, prospective data are needed on how different treatment regimens affect outcome. The aims of this prospective trial are to determine effectiveness, safety, and clinical outcome of multimodal treatment in patients with extracranial AVMs. MATERIALS AND METHODS After clinical and magnetic resonance imaging (MRI)-based diagnosis and informed consent, 146 patients (> 4 years and < 70 years) undergoing multimodal therapy in tertiary care vascular anomalies centers will be included in this prospective observational trial. Treatment options include conservative management, medical therapy, minimally invasive image-guided procedures (embolization, sclerotherapy) and surgery as well as combinations of the latter. The primary outcome is the patient-reported QoL 6 months after completion of treatment using the short form-36 health survey version 2 (SF-36v2) and the corresponding short form-10 health survey (SF-10) for children. In addition, clinical presentation (physician-reported signs), MRI imaging (radiological assessment of devascularization), recurrence rate, and therapeutic safety will be analyzed. Further follow-up will be performed after 12, 24, and 36 months. Moreover, liquid biopsies are being obtained from peripheral blood at multiple time points to investigate potential biomarkers for therapy response and disease progression. DISCUSSION The APOLLON trial is a prospective, multicenter, observational open-label trial with unequal study groups to generate prospective evidence for multimodal treatment of AVMs. A multicenter design with the potential to assess larger populations will provide an increased understanding of multimodal therapy outcome in this orphan disease. TRIAL REGISTRATION German Clinical Trials Register (identification number: DRKS00021019) https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021019 .
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Affiliation(s)
- Vanessa F. Schmidt
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Max Masthoff
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Veronika Vielsmeier
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - Caroline T. Seebauer
- Department of Otorhinolaryngology, University Hospital Regensburg, Regensburg, Germany
| | - Özlem Cangir
- Department of Pediatric Surgery, Center for Vascular Malformations, Klinikum Barnim GmbH, Werner Forssmann Hospital, Eberswalde, Germany
| | - Lutz Meyer
- Department of Pediatric Surgery, Center for Vascular Malformations, Klinikum Barnim GmbH, Werner Forssmann Hospital, Eberswalde, Germany
| | - Antje Mükke
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Axel Schmid
- Department for Radiology, University Hospital Erlangen, Erlangen, Germany
| | - Peter B. Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Richard Brill
- Clinic and Policlinic of Diagnostic Radiology, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Walter A. Wohlgemuth
- Clinic and Policlinic of Diagnostic Radiology, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | | | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Regina Schinner
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Julia Küppers
- Department for Pediatric Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Beate Häberle
- Department for Pediatric Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Frank Haubner
- Department of Otorhinolaryngology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Martin Zenker
- Institute for Human Genetics, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Melanie A. Kimm
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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Bhatia K, Lee H, Kortman H, Klostranec J, Guest W, Wälchli T, Radovanovic I, Krings T, Pereira V. Endovascular Management of Intracranial Dural Arteriovenous Fistulas: Transarterial Approach. AJNR Am J Neuroradiol 2022; 43:324-331. [PMID: 34620593 PMCID: PMC8910823 DOI: 10.3174/ajnr.a7296] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/03/2021] [Indexed: 01/02/2023]
Abstract
In this second of 3 review articles on the endovascular management of intracranial dural AVFs, we discuss transarterial treatment approaches. The treatment goal is to occlude the fistulous point, including the most distal portion of the arterial supply together with the most proximal portion of the draining vein (ie, the "foot" of the vein), which can be accomplished with liquid embolic agents via transarterial access. Anatomic factors to consider when assessing the safety and efficacy of a transarterial approach using liquid embolic agents include location, angioarchitecture, and proximity of arterial feeders to both the vasa nervosum of adjacent cranial nerves and the external carotid-internal carotid/vertebral artery anastomoses. Anatomic locations typically favorable for transarterial approaches include but are not limited to the transverse/sigmoid sinus, cerebral convexity, and superior sagittal sinus. In this review article, we discuss the technical approaches, outcomes, potential complications, and complication avoidance strategies for transarterial embolization.
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Affiliation(s)
- K.D. Bhatia
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.),Department of Medical Imaging (K.D.B.), Sydney Children’s Hospital Network, Westmead, New South Wales, Australia,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of Sydney, Camperdown, New South Wales, Australia,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia,Division of Medical Imaging (K.D.B.), Faculty of Medicine, Macquarie University, Macquarie Park, New South Wales, Australia
| | - H. Lee
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - H. Kortman
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - J. Klostranec
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - W. Guest
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - T. Wälchli
- Neurosurgery (T.W., I.R., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - I. Radovanovic
- Neurosurgery (T.W., I.R., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T. Krings
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.),Neurosurgery (T.W., I.R., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - V.M. Pereira
- Division of Interventional Neuroradiology (V.M.P.), St Michael’s Hospital, Toronto, Ontario, Canada
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Systematic review of pediatric mandibular arteriovenous malformations. Int J Pediatr Otorhinolaryngol 2021; 150:110942. [PMID: 34673419 DOI: 10.1016/j.ijporl.2021.110942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 09/28/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The management of arteriovenous malformations (AVMs) can be challenging in the pediatric population. It is of utmost importance to keep in mind various management options as these lesions can have disastrous outcomes. This is a systematic review of the treatment AVMs describing the current practices so that practitioners can be aware of what is currently reported in the literature. The challenges of AVM management can be mitigated when approaching these patients through a multidisciplinary team-based approach. METHODS A systematic review of the literature was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to gain insight into pediatric mandibular AVMs. Demographics, arterial involvement, clinical symptoms, imaging, treatment, complications, follow-up, and outcomes were reviewed. RESULTS 63 articles were included in the systematic review with 106 distinct cases. The age range was from 3 to 17 years with a mean of 12 years. 51% of the patients were female. The most common clinical presentation was emergency hemorrhage (37.4%), swelling or edema (33.0%), and persistent bleeding (31.9%). The most common CT findings were osteolytic changes and radiolucencies (60.8%). With regards to treatment, 56.6% of patients had embolization alone and 34.9% were treated with embolization in combination with other surgical treatments. Of the patients who had surgical resection of the lesion, 50% had resection followed by reconstruction, 23.7% had curettage of the lesion, and 13.2% had resection/curettage then immediate reimplantation of the mandible segment. The most common complications after intervention included bleeding in 17.9% of patients and infection in 8.3% of patients. 89.5% of patients were clinically cured without recurrence at follow-up. CONCLUSION Diagnosing AVMs can be difficult as they have variable clinical and radiographical presentations. Although rare, because of risk of massive hemorrhage, it is important for healthcare professionals to be aware of this pathology. Many surgical techniques, routes of embolization, embolic material, and other experimental therapies have been described and this review shows that the most cases had embolization as a part of the treatment. The role of therapies targeted at the molecular level still needs to be further explored.
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12
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Matsoukas S, Bageac D, Yaeger K, Berenstein A, T Fifi J, Shigematsu T. Initial experience with the Scepter Mini catheter for the embolization of vascular malformations in the pediatric population. Neuroradiol J 2021; 35:520-526. [PMID: 34609932 PMCID: PMC9437497 DOI: 10.1177/19714009211049084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Achieving distal access and flow control are of significant importance for the treatment of intracerebral arteriovenous shunting lesions. The Scepter Mini catheter is a low-profile, dual-lumen balloon catheter, designed to provide navigability in small-caliber, tortuous intracranial vessels. OBJECTIVE To describe the initial experience of the Scepter Mini catheter in the treatment of pediatric arteriovenous malformations and fistulas. METHODS A single-institution, retrospective chart review identified all consecutive uses of the Scepter Mini catheter for endovascular embolization of vascular malformations in the pediatric population. RESULTS Three different arterial pedicles were embolized with the Scepter Mini catheter in two different patients. One patient was diagnosed with a vein of Galen malformation that had undergone multiple treatments and the other with a torcular dural arteriovenous fistula. All cases encompassed quite challenging tortuosity of small-caliber feeders which prevented the use of another microcatheter. The Scepter Mini catheter navigated into feeding arteries of diameters 0.65, 1.9, and 1.25 mm, and its balloon was inflated to achieve excellent blood flow control. Total obliteration (100%) of the shunting lesion was achieved in both cases. No reflux, pedicle rupture or other untoward effects were observed. Both patients had an uneventful recovery. CONCLUSION The Scepter Mini catheter afforded fast and safe distal access, flow control, and treatment of arteriovenous malformations in this initial pediatric cohort. The catheter's low profile and easy navigability should support its use in tortuous and small arterial feeders, especially in the pediatric population.
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Affiliation(s)
- Stavros Matsoukas
- Department of Neurosurgery, 5864The Mount Sinai Hospital, The Mount Sinai Hospital, USA
| | - Devin Bageac
- Department of Neurosurgery, 5864The Mount Sinai Hospital, The Mount Sinai Hospital, USA
| | - Kurt Yaeger
- Department of Neurosurgery, 5864The Mount Sinai Hospital, The Mount Sinai Hospital, USA
| | - Alejandro Berenstein
- Department of Neurosurgery, 5864The Mount Sinai Hospital, The Mount Sinai Hospital, USA
| | - Johanna T Fifi
- Department of Neurosurgery, 5864The Mount Sinai Hospital, The Mount Sinai Hospital, USA
| | - Tomoyoshi Shigematsu
- Department of Neurosurgery, 5864The Mount Sinai Hospital, The Mount Sinai Hospital, USA
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13
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Cekirge HS, Saatci I. Multiplug flow control technique as a novel transarterial curative approach for the endovascular treatment of cerebrovascular malformations. BMJ Case Rep 2021; 14:1-3. [PMID: 33947684 PMCID: PMC8098918 DOI: 10.1136/bcr-2021-017418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/27/2022] Open
Abstract
Herein, we describe the use of a novel multiplug flow control technique for the curative transarterial embolisation of cerebrovascular malformations using liquid embolic agents (LEAs). The idea behind the use of this technique is to substantially control or arrest flow during LEA injection, with multiple plugs simultaneously formed from microcatheters that are placed within all or multiple feeders, so that the penetration of LEAs is facilitated, with flow control decreasing the washout of a malformation. This technique enables the complete occlusion of a vascular malformation in a shorter injection time than that in other methods because penetration is achieved faster. Details of this technique have been described in the treatment of two cases: one case of unruptured temporal arteriovenous malformation and in the other with a falcotentorial dural arteriovenous fistula, in which the vascular malformations were successfully occluded with transarterial embolisation.
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Affiliation(s)
- H Saruhan Cekirge
- Radiology Department, Private Koru Hospital, Ankara, Turkey
- Independent Researcher, Ankara, Turkey
| | - Isil Saatci
- Radiology Department, Private Koru Hospital, Ankara, Turkey
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14
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Albuquerque TVC, Stamoulis DNJ, Monsignore LM, de Castro-Afonso LH, Nakiri GS, Rezende MT, Trivelato FP, Vanzin JR, Ulhoa AC, G Abud D. The use of dual-lumen balloon for embolization of peripheral arteriovenous malformations. Diagn Interv Radiol 2021; 27:225-231. [PMID: 33517257 DOI: 10.5152/dir.2021.19628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE We aimed to evaluate the safety and feasibility of the embolization of peripheral arteriovenous malformation (AVM) with non-adhesive liquid agents (NALA) injected by dual-lumen balloons (DLB). METHODS We conducted a multicenter retrospective study between January 2017 and June 2019, including patients with peripheral AVM embolized with NALA by DLB. Fourteen patients were included. The AVM classification, technical and clinical success were evaluated, as were nidus size, liquid agent used, volume and time of injection in DLB, complications, follow-up and need of surgical intervention. RESULTS The mean age of the patients was 37±22.5 years (range, 6-82 years). The mean nidus size was 5.2±2.4 cm (range, 3.0-12.0 cm). By Schobinger classification, 11 AVMs were classified in stage 3 and 3 AVMs were classified in stage 2. By Cho's classification, 2 AVMs were in stage II, 4 AVMs were in stage I, 4 AVMs were in stage IIIa and 4 AVMs were in stage IIIb. Onyx was used in 11 patients (78.6%), while Squid, PHIL, and both Onyx and Squid were used in one patient each (7.1%). Seven patients (50%) required one session of embolization, 4 patients (28.6%) required two, 2 patients (14.3%) required three and 1 patient (7.1%) required four sessions. Complete nidus exclusion was achieved in 11 patients (78.6%), optimal clinical response in 12 patients (85.7%). Four patients (28.6%) exhibited minor complications, all controlled. No major complications were seen. Four patients underwent surgical intervention (28.6%). CONCLUSION The embolization of peripheral AVM with NALA in DLB appears to be safe and feasible, achieving high rates of technical and clinical success.
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Affiliation(s)
- Tales V C Albuquerque
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Dimitrius Nikolaos Jaconi Stamoulis
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Lucas M Monsignore
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Luis Henrique de Castro-Afonso
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Marco Tulio Rezende
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Felipe Padovani Trivelato
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - José Ricardo Vanzin
- Division of Interventional Neuroradiology, Clinics Hospital, Passo Fundo, Rio Grande do Sul, Brazil
| | - Alexandre Cordeiro Ulhoa
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel G Abud
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
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Mattay RR, Shlansky-Goldberg R, Pukenas BA. Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization. CVIR Endovasc 2021; 4:4. [PMID: 33400002 PMCID: PMC7785756 DOI: 10.1186/s42155-020-00200-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background Although 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 presentation In 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). Conclusions The 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.
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Affiliation(s)
- Raghav R Mattay
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Richard Shlansky-Goldberg
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Bryan A Pukenas
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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16
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Hafazalla K, Baldassari MP, Sweid A, Starke R, Sajja K, Lebovitz J, Storey C, Herial N, Tjoumakaris S, Gooch MR, Zarzour H, Rosenwasser R, Jabbour P. A comparison of dual-lumen balloon and simple microcatheters in the embolization of DAVFs and AVMs using onyx. J Clin Neurosci 2020; 81:295-301. [PMID: 33222933 DOI: 10.1016/j.jocn.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/14/2020] [Accepted: 10/03/2020] [Indexed: 11/27/2022]
Abstract
Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30-0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04-0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00-11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs.
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Affiliation(s)
- Karim Hafazalla
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Michael P Baldassari
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Robert Starke
- Department of Neurological Surgery, University of Miami, Miami, FL, United States
| | - Kalyan Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Jonathon Lebovitz
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Christopher Storey
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Robert Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States.
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17
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Zamponi JO, Trivelato FP, Rezende MTS, Freitas RK, de Castro-Afonso LH, Nakiri GS, Abud TG, Ulhôa AC, Abud DG. Transarterial Treatment of Cranial Dural Arteriovenous Fistulas: The Role of Transarterial and Transvenous Balloon-Assisted Embolization. AJNR Am J Neuroradiol 2020; 41:2100-2106. [PMID: 33004343 DOI: 10.3174/ajnr.a6777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/07/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Treatment of dural arteriovenous fistulas can be performed by transarterial or transvenous accesses. For those fistulas located at a dural sinus wall, obliteration of the sinus might lead to a substantial risk of complications if the occluded sinus impairs normal venous drainage. For those fistulas with direct leptomeningeal venous drainage, navigation to reach the arteriovenous shunting point of a leptomeningeal vein is usually technically demanding. We report the outcomes of patients with dural AVFs treated by transarterial injection of liquid embolic agents assisted by transarterial double-lumen balloon catheters and/or transvenous balloon catheters. MATERIALS AND METHODS This was a retrospective, 3-center study including patients with dural AVFs treated with a balloon-assisted technique in at least 1 treatment session. Angiographic follow-up was performed at 6 months. Clinical assessment was performed at admission and discharge and was reassessed at 30-day and 6-month follow-ups. RESULTS Forty-one patients with 43 dural AVFs were treated. Thirty-four fistulas were located at a dural sinus wall. Treatment was performed using only a transarterial approach in 42 fistulas. Only 1 session was needed for complete obliteration of the fistula in 86% of the patients. Immediate complete angiographic occlusion was achieved in 39 fistulas. Of the 41 controlled fistulas, 40 (97.6%) were completely occluded at 6 months. Thirty-nine fistulas (95.1%) were cured without any report of major neurologic events or death during follow-up. CONCLUSIONS Transarterial balloon-assisted treatment of dural AVFs with or without transvenous balloon protection was shown to be safe and effective.
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Affiliation(s)
| | - F P Trivelato
- From the Division of Interventional Neuroradiology (J.O.Z., F.P.T., M.T.S.R., A.C.U.), Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - M T S Rezende
- From the Division of Interventional Neuroradiology (J.O.Z., F.P.T., M.T.S.R., A.C.U.), Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - R K Freitas
- Division of Interventional Neuroradiology (R.K.F., L.H.d.C.-A., G.S.N., D.G.A.), Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - L H de Castro-Afonso
- Division of Interventional Neuroradiology (R.K.F., L.H.d.C.-A., G.S.N., D.G.A.), Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - G S Nakiri
- Division of Interventional Neuroradiology (R.K.F., L.H.d.C.-A., G.S.N., D.G.A.), Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - T G Abud
- Division of Interventional Neuroradiology (T.G.A.), Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - A C Ulhôa
- From the Division of Interventional Neuroradiology (J.O.Z., F.P.T., M.T.S.R., A.C.U.), Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - D G Abud
- Division of Interventional Neuroradiology (R.K.F., L.H.d.C.-A., G.S.N., D.G.A.), Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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18
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Tyler Patterson T, Webb M, Wallace DJ, Caron JL, Mascitelli JR. Suboccipital, Supracerebellar, Infratentorial Approach for Microsurgical Clipping of a Ruptured Tentorial, Straight Sinus Type Dural Arteriovenous Fistula. World Neurosurg 2020; 142:131-135. [PMID: 32565382 DOI: 10.1016/j.wneu.2020.06.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVFs) can often be successfully treated with endovascular embolization; however, surgery is occasionally still required. CASE DESCRIPTION Herein, we discuss a 65-year-old male patient who presented with a Hunt-Hess IV subarachnoid hemorrhage, intraventricular hemorrhage, and cerebellar intracranial hemorrhage secondary to a ruptured Borden type III tentorial (straight sinus) dAVF. Angiography revealed supply from the left occipital and posterior meningeal arteries and direct drainage into the cerebellar cortical veins with venous aneurysms in both cerebellar hemispheres. Both transarterial and transvenous embolization were attempted, without success. Therefore, the patient was taken to the operating room for clip ligation of the dAVF. The operative video demonstrates a bilateral suboccipital craniotomy and supracerebellar infratentorial approach for surgical clipping of the dAVF. CONCLUSIONS The case and operative video provide a valuable addition to surgical literature in an era where surgical management of dAVFs has become relatively rare.
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Affiliation(s)
- Thomas Tyler Patterson
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Matthew Webb
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - David J Wallace
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
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Kurabe S, Ito Y, Kumagai T. Balloon-assisted Onyx Embolization in the Management of Complicated Dural Arterioevenous Fistula. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:358-365. [PMID: 37501666 PMCID: PMC10370911 DOI: 10.5797/jnet.oa.2020-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/30/2020] [Indexed: 07/29/2023]
Abstract
Objective 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. Methods 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. Results 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. Conclusion 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.
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Affiliation(s)
- Satoshi Kurabe
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Niigata, Japan
| | - Yasushi Ito
- Department of Neurosurgery, Shinrakuen Hospital, Niigata, Niigata, Japan
| | - Takashi Kumagai
- Department of Neurosurgery, Yamagata Prefectural Central Hospital, Yamagata, Yamagata, Japan
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20
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Pulli B, Sussman ES, Mayercik V, Steinberg GK, Do HM, Heit JJ. Initial experience with the Scepter Mini dual-lumen balloon for transophthalmic artery embolization of anterior cranial fossa dural arteriovenous fistulae. J Neurointerv Surg 2020; 12:1132-1136. [PMID: 32434799 DOI: 10.1136/neurintsurg-2020-016013] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Precise delivery of liquid embolic agents (LEAs) remains a challenge in the endovascular treatment of dural arteriovenous fistulae (dAVFs) and cerebral arteriovenous malformations (cAVMs). Despite significant advances in the past decade, LEA reflux and catheter navigability remain shortcomings of current endovascular technology, particularly in small and tortuous arteries. The Scepter Mini dual-lumen balloon microcatheter aims to address these issues by decreasing the distal catheter profile (1.6 French) while allowing for a small (2.2 mm diameter) balloon at its tip. METHODS We report our initial experience with the Scepter Mini in two patients with anterior cranial fossa dAVFs that were treated with transophthalmic artery embolization. RESULTS In both patients, the Scepter Mini catheter was able to be safely advanced into the distal ophthalmic artery close to the fistula site, and several centimeters past the origins of the central retinal and posterior ciliary arteries. A single Onyx injection without any reflux resulted in angiographic cure of the dAVF in both cases, and neither patient suffered any vision loss. CONCLUSIONS These initial experiences suggest that the Scepter Mini represents a significant advance in the endovascular treatment of dAVFs and cAVMs and will allow for safer and more efficacious delivery of LEAs into smaller and more distal arteries while diminishing the risk of LEA reflux.
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Affiliation(s)
- Benjamin Pulli
- Radiology, Neurointervention Division, Stanford University School of Medicine, Stanford, California, USA
| | - Eric S Sussman
- Neurosurgery and Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Vera Mayercik
- Radiology, Neurointervention Division, Stanford University School of Medicine, Stanford, California, USA
| | - Gary K Steinberg
- Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Huy M Do
- Radiology, Neurointervention Division, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University School of Medicine, Stanford, California, USA
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21
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Ho FL, Chapot R. Removal of distal fragments of liquid embolic agents during arteriovenous malformation embolization using the TIGERTRIEVER 13: a technical report. J Neurointerv Surg 2020; 12:794-797. [PMID: 32024783 DOI: 10.1136/neurintsurg-2019-015474] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are vascular lesions that may be treated by an endovascular approach using liquid embolic agents but the control of the liquid embolic agent remains poor and a potential complication may be distal migration of embolic material. The TIGERTRIEVER 13 is a new stent retriever designed for stroke thrombectomy and has a version ideal for distal occlusions. We report our experience in the removal of embolic agent which had migrated into the distal vessels using the TIGERTRIEVER during PHIL/Onyx embolization of AVMs. CLINICAL PRESENTATIONS Three patients with brain and spinal AVMs underwent endovascular embolization. During trans-arterial embolization of the AVM with PHIL/Onyx, retrograde filling of distal arterial feeders was followed by migration into the normal arterial branches (cortical middle cerebral artery, distal posterior cerebral artery, and anterior spinal artery). This resulted in occlusion or sluggish distal flow in these branches with potential significant neurological deficits. In all three cases, a Headway Duo microcatheter was navigated distally in the occluded vessel beyond the embolic material using a Traxcess microwire. The TIGERTRIEVER 13 was deployed with recanalization of the vessel after a single attempt. In all three patients there were no complications related to the retrieval of embolic agent. CONCLUSION Distal migrated embolic agents such as PHIL or Onyx can be removed from various arterial vascular territories using stent retrievers dedicated to small vessels.
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Affiliation(s)
- Faith Ly Ho
- Neurosurgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong
| | - René Chapot
- Neuroradiology, Alfried Krupp Krankenhaus Ruttenscheid, Essen, Germany
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22
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Piao J, Ji T, Guo Y, Xu K, Yu J. Brain arteriovenous malformation with transdural blood supply: Current status. Exp Ther Med 2019; 18:2363-2368. [PMID: 31555346 PMCID: PMC6755268 DOI: 10.3892/etm.2019.7731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/31/2019] [Indexed: 12/15/2022] Open
Abstract
Arterial blood supply to a brain arteriovenous malformation (BAVM) is mainly derived from the internal carotid artery (ICA) and vertebral basilar artery (VBA) system. However, in certain cases, arteries supplying the meninges may also contribute to the blood supply of the BAVM, resulting in the formation of a BAVM with transdural blood supply (TBS). To review the current status of BAVM with TBS, a literature search was performed in the PubMed database. Articles were screened for relevance and suitability of data. According to recent studies, the mechanisms by which TBS to a BAVM forms are mainly classified into the congenital and acquired type. BAVM with TBS is common in elderly patients and is characterized by intracranial hemorrhage, epilepsy, chronic headache and increased intracranial pressure. Digital subtraction angiography is the gold standard for diagnosing BAVM with TBS. Superselective angiography is also important. Treatments for BAVM with TBS include surgical resection, endovascular treatment (EVT), stereotactic radiosurgery and combined treatment. Surgical resection is difficult to perform. EVT has become the major therapy for treating BAVM with TBS due to its low procedural invasiveness. Combination of surgical resection and EVT may be a good option. In addition, stereotactic radiosurgery is frequently used as a complementary treatment to surgical and endovascular interventions. The prognosis of BAVM with TBS is not favorable, as the defect involves a complex arterial supply system.
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Affiliation(s)
- Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Tiefeng Ji
- Department of Radiology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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23
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Griffin AS, Befera N, Hauck E. Onyx embolization of a pial AV fistula with a giant venous varix using a flow-directed Scepter balloon catheter: Technical note. Interv Neuroradiol 2018; 24:702-705. [PMID: 29921152 DOI: 10.1177/1591019918781670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Pial arteriovenous fistulas (AVFs) of the brain are treacherous lesions that can be challenging to treat because of high risk of hemorrhage. We report on a rare case of a pial AVF with a giant venous varix as a draining vein treated successfully with flow-directed balloon-assisted Onyx embolization. CLINICAL PRESENTATION A 56-year-old female with headaches underwent brain magnetic resonance imaging, which demonstrated a 4 cm aneurysmal malformation in the right temporal lobe. A diagnostic cerebral angiogram demonstrated a right temporal pial AVF fed by an enlarged right posterior cerebral artery with drainage into a giant venous varix. Onyx embolization was curative using a flow-directed Scepter balloon catheter. CONCLUSION Flow-directed balloon-assisted Onyx embolization can be highly successful for the curative embolization of pial AVFs. Balloon application changes the nature of the lesion from high-flow-high risk to no-flow-low-risk. Using a flow-directed technique with balloon microcatheters may help minimize the risk of intracranial vascular injury.
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Affiliation(s)
- Andrew S Griffin
- 1 Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Nicholas Befera
- 1 Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Erik Hauck
- 2 Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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24
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Jagadeesan BD, Grande AW, Tummala RP. Safety and Feasibility of Balloon-Assisted Embolization with Onyx of Brain Arteriovenous Malformations Revisited: Personal Experience with the Scepter XC Balloon Microcatheter. INTERVENTIONAL NEUROLOGY 2018; 7:439-444. [PMID: 30410522 DOI: 10.1159/000490579] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
Background/Objective Compliant dual-lumen balloon microcatheters have been used to perform balloon-assisted embolization (BAE) of brain arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (Onyx). However, vessel rupture and microcatheter retention have been reported from BAE using these microcatheters. Using an extra-compliant balloon microcatheter (Scepter XC; Microvention, Tustin, CA, USA) could help avoid pial vessel rupture during BAE. We herein report our experience using this balloon microcatheter for BAE. Methods This retrospective study included patients who underwent BAE of brain AVMs at our institution between June 2012 and March 2017. Results The extra-compliant Scepter XC balloon microcatheter was used for BAE of brain AVMs in 23 patients aged 44.3 ± 16.7 years (range 0-65 years). A total of 40 intracranial vessels (39 pial arteries and 1 pial vein) were catheterized and embolized during 30 separate sessions. In all instances, the balloon microcatheter could be successfully advanced to the AVM nidus. A mean volume of 2.4 ± 1.7 mL (range 0.65-4.6 mL) of Onyx was injected per session. There were no instances of vessel rupture, microcatheter retention, or stroke. Conclusion Utilization of the extra-compliant balloon microcatheter results in safe and effective BAE, which adds to the growing experience with BAE for AVM treatment.
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Affiliation(s)
- Bharathi D Jagadeesan
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew W Grande
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ramachandra P Tummala
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
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25
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Kim SH, Kim TG, Kong MH. Transarterial Balloon-assisted Onyx Embolization of Intracranial Arteriovenous Malformations Using a Dual-lumen Balloon Microcatheter: Two Case Reports. J Cerebrovasc Endovasc Neurosurg 2017; 19:223-230. [PMID: 29159158 PMCID: PMC5680088 DOI: 10.7461/jcen.2017.19.3.223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/22/2017] [Accepted: 09/21/2017] [Indexed: 11/23/2022] Open
Abstract
The Onyx system has been well established in recent years as a very important material in the treatment of arteriovenous malformations (AVMs). When using the Onyx, it is essential to wait for the creation of a plug around the tip of the catheter, which enables the effective forward penetration of Onyx. Recent reports have shown that the introduction of a dimethyl sulfoxide compatible dual-lumen balloon microcatheter improves the efficiency of AVM embolization. We report our recent experience of two cases of intracranial AVM embolization using Onyx and the transarterial balloon-assisted technique. In both cases, the procedures were successfully performed and the nidus of the AVM was totally occluded in a relatively short time. This technique may enable immediate forward flow and penetration of Onyx without concern about reflux. It may also reduce the procedure time and increase the angiographic occlusion rate. Navigation of the dual-lumen balloon microcatheter nevertheless remains a challenge.
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Affiliation(s)
- Sang Heum Kim
- Department of Neuroradiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Tae Gon Kim
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
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26
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Piechowiak E, Zibold F, Dobrocky T, Mosimann PJ, Bervini D, Raabe A, Gralla J, Mordasini P. Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus. AJNR Am J Neuroradiol 2017; 38:1984-1989. [PMID: 28818827 DOI: 10.3174/ajnr.a5333] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/01/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Combined transarterial balloon-assisted endovascular embolization with double-lumen balloon microcatheters and concomitant transvenous balloon protection was described as a promising treatment technique for dural arteriovenous fistulae of the transverse and sigmoid sinus. The purpose of this study was to evaluate the technical efficacy and safety of this combined treatment technique. MATERIALS AND METHODS Nine consecutive patients presenting with dural arteriovenous fistulas of the transverse and sigmoid sinuses underwent combined transarterial and transvenous balloon-assisted endovascular embolization. Prospectively collected data were reviewed to assess the technical success rate, complication rate, and clinical outcome. RESULTS Six patients presented with clinically symptomatic Borden type I, and 3 patients, with Borden type II dural arteriovenous fistulas of the transverse and sigmoid sinuses (3 men, 6 women; mean age, 50.4 years). Transarterial embolization was performed with a double-lumen balloon with Onyx and concomitant transvenous sinus protection with a dedicated venous remodeling balloon. Complete angiographic occlusion at the latest follow-up (mean, 4.8 months) was achieved in 6 patients, and near-complete occlusion, in 2 patients. Clinical cure or remission of symptoms was obtained in 6 and 2 patients, respectively. One patient with a residual fistula underwent further treatment in which the dural arteriovenous fistula was cured by sinus occlusion. Complete occlusion of the dural arteriovenous fistula was visible on the follow-up angiography after final treatment in 8 patients. One patient refused follow-up angiography but was free of symptoms. There were no immediate or delayed postinterventional complications. CONCLUSIONS Transarterial balloon-assisted embolization of dural arteriovenous fistulas of the transverse and sigmoid sinuses with combined transvenous balloon protection is safe and offers a high rate of complete dural arteriovenous fistula occlusion and remission of clinical symptoms.
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Affiliation(s)
- E Piechowiak
- From the University Institute of Diagnostic and Interventional Neuroradiology (E.P., F.Z., T.D., J.G., P.M., P.J.M.)
| | - F Zibold
- From the University Institute of Diagnostic and Interventional Neuroradiology (E.P., F.Z., T.D., J.G., P.M., P.J.M.)
| | - T Dobrocky
- From the University Institute of Diagnostic and Interventional Neuroradiology (E.P., F.Z., T.D., J.G., P.M., P.J.M.)
| | - P J Mosimann
- From the University Institute of Diagnostic and Interventional Neuroradiology (E.P., F.Z., T.D., J.G., P.M., P.J.M.)
| | - D Bervini
- Department of Neurosurgery (D.B., A.R.), Inselspital, University of Bern, Bern, Switzerland
| | - A Raabe
- Department of Neurosurgery (D.B., A.R.), Inselspital, University of Bern, Bern, Switzerland
| | - J Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (E.P., F.Z., T.D., J.G., P.M., P.J.M.)
| | - P Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (E.P., F.Z., T.D., J.G., P.M., P.J.M.)
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27
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Gross BA, Tonetti DA, Weiner GM, Panczykowski DM, Ares WJ, Kenmuir CL, Jadhav AP, Jovin TG, Jankowitz BT. Septoplasty: Scepter Balloon Angioplasty for Vasospasm after Aneurysmal Subarachnoid Hemorrhage. INTERVENTIONAL NEUROLOGY 2017; 6:229-235. [PMID: 29118800 DOI: 10.1159/000477467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction Balloon angioplasty can be a requisite approach for the treatment of symptomatic and/or severe vasospasm. Dual-lumen microcatheter balloons have multiple potential advantages for this indication including accommodating a 0.014-inch wire and the potential to deliver superselective vasodilators directly via the microcatheter prior to angioplasty. Methods The authors reviewed a 3-year institutional experience with the Scepter XC balloon (Microvention, Tustin, CA, USA) in the treatment of postaneurysmal subarachnoid hemorrhage vasospasm, focusing on treatment methods, angiographic, and clinical results. Results Sixty-four vessels were treated in 18 patients. Fifteen cases were performed under intravenous (i.v.) conscious sedation (83%). The mean pretreatment stenosis was 59% (range 40-80), and the mean post-treatment stenosis was 12% (range 0-40). Five vessels in 3 patients were subsequently retreated via angioplasty for recurrent vasospasm (8%). There were no complications related to the passage of the balloon microcatheter or inflation of the balloon such as dissection or vessel rupture. Of 14 patients with delayed cerebral ischemia, 7 had complete symptomatic resolution after treatment, and 3 had significant symptomatic improvement. Four patients did not improve after treatment though 3 already had confirmed infarcts on imaging prior to angiography. Conclusion The Scepter XC is a safe and effective balloon microcatheter for angioplasty of cerebral vasospasm after subarachnoid hemorrhage, allowing for superselective delivery of a vasodilator. Its ease of deliverability and visibility often allows for the performance of the procedure under i.v. conscious sedation.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Cynthia L Kenmuir
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tudor G Jovin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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28
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Amorim JM, Rosati S, Agid R, Pereira VM, Krings T. Treatment of an internal carotid artery aneurysm with a flow diverter through a double lumen balloon catheter. Interv Neuroradiol 2017; 23:255-259. [PMID: 28604183 DOI: 10.1177/1591019917691238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Double lumen balloon catheters (DLBCs) are currently used in the treatment of intracranial aneurysms, especially when involving balloon or stent-assisted coiling. The existing DLBCs allow the delivery of self-expandable stents but do not offer the possibility to deploy flow-diverters. Despite the increasing use and success of flow-diverters, there have been numerous reports of procedural complications such as early in-stent thrombosis or delayed distal embolization. It seems that these complications can be avoided by correct stent positioning and adequate wall apposition, achieved either by manoeuvres with the microguidewire and/or microcatheter or by performing balloon angioplasty following an exchange guidewire manoeuvre. Objective Report the use of a new DLBC able to deliver a flow-diverter. Methods A 41-year-old woman presented to our hospital with binocular horizontal diplopia for two weeks and reduced visual acuity. A left internal carotid artery aneurysm involving the cavernous and ophthalmic segments was found, with a maximum height of 19 mm and a broad 8 mm neck. It presented extra- and intra-dural components and the parent vessel was significantly narrowed. A decision was made to perform endovascular treatment of the aneurysm with placement of a flow diverter through a DLBC. Results Patency and adequate expansion of the flow diverter with evident intra-aneurysmal contrast stasis was observed in the final angiogram. No peri-procedural complications were observed. Conclusion This is a technical note demonstrating the feasibility of a new device to deploy a flow diverter, aiming to improve wall apposition and stent configuration without the need of additional devices or exchange manoeuvres.
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Affiliation(s)
- José M Amorim
- 1 Neuroradiology Department, Hospital de Braga, Braga, Portugal
| | - Santiago Rosati
- 2 Neuroradiology Department, Clinical San Carlos Hospital, Madrid, Spain
| | - Ronit Agid
- 3 Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital, University Health Network, Canada
| | - Vítor Mendes Pereira
- 3 Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital, University Health Network, Canada.,4 Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto Western Hospital, University Health Network, Canada
| | - Timo Krings
- 3 Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital, University Health Network, Canada.,4 Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto Western Hospital, University Health Network, Canada
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29
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Clarençon F, Di Maria F, Gabrieli J, Carpentier A, Pistochi S, Bartolini B, Zeghal C, Chiras J, Sourour NA. Double-lumen balloon for Onyx® embolization via extracranial arteries in transverse sigmoid dural arteriovenous fistulas: initial experience. Acta Neurochir (Wien) 2016; 158:1917-23. [PMID: 27522356 DOI: 10.1007/s00701-016-2906-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
Transverse-sigmoid dural arteriovenous fistulas (TS DAVFs) can be challenging to treat by endovascular means. Indeed, a total cure of the fistula can only be achieved when complete occlusion of the fistulous point(s) is obtained by penetration of the embolic agent. However, in some cases, especially for transosseous branches from extracranial arteries like the occipital artery (OcA) or the superficial temporal artery (STA), such penetration is usually poor, leading to major proximal reflux and incomplete fistula obliteration. We present three cases of embolization in two patients with TS DAVF through the OcA and/or the STA with Onyx® using a double-lumen balloon (Microvention, Tustin, CA, USA). This technique allows the penetration of the embolic agent in the transosseous branches by forming a counter-pressure with the inflated balloon. This technique may be useful to achieve complete occlusion of TS DAVFs by endovascular means.
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30
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Meila D, Grieb D, Greling B, Melber K, Jacobs C, Hechtner M, Schmitz T, Schlunz-Hendann M, Lanfermann H, Brassel F. Endovascular treatment of head and neck arteriovenous malformations: long-term angiographic and quality of life results. J Neurointerv Surg 2016; 9:860-866. [DOI: 10.1136/neurintsurg-2016-012570] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 08/02/2016] [Accepted: 08/05/2016] [Indexed: 01/12/2023]
Abstract
AimTo present the long-term angiographic and subjective results of patients with head and neck arteriovenous malformations (HNAVMs) after endovascular treatment.MethodsWe retrospectively analyzed the medical files of 14 patients with HNAVM who were treated between 2000 and 2014. The treatment of choice was a transarterial superselective microcatheter-based approach followed by embolization using liquid embolic agents. The patients were asked to answer a quality of life questionnaire about the following symptoms before and after treatment: pain, functional impairment, cosmetic deformity, impairment in daily life, and bleeding.ResultsComplete or >90% closure of the AVM was achieved in 6 of 14 patients (43%). >50% shunt reduction was achieved in 10 patients (71%). Three complications were encountered in a total of 86 interventional procedures. Six patients presented with bleeding which was cured in all cases (100%). Four of the 14 patients (29%) specified pain which was resolved in two of them. Another six patients (43%) presented with functional impairment; four were cured and two noted an improvement. All 14 patients presented with cosmetic concerns; four were cured and eight experienced a clearly visible improvement. Nine of 13 patients (69%) presented with impairment in daily life which was resolved in five patients and four reported an improvement.ConclusionsEndovascular embolization is a well-tolerated therapy for HNAVM with a low complication rate. Good angiographic results, positive subjective results, and improvement in different aspects of quality of life can be achieved.
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31
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Heit J, Connolly I, Choudhri O. Percutaneous use of a dual lumen Scepter XC balloon for embolization of a complex facial arteriovenous malformation: a technical report. Clin Neuroradiol 2016; 26:485-491. [PMID: 27142059 DOI: 10.1007/s00062-016-0515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Jeremy Heit
- Department of Radiology, Stanford University Medical Center, 300 Pasteur Drive, 94305, Stanford, CA, USA
| | - Ian Connolly
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive, 94305, Stanford, CA, USA
| | - Omar Choudhri
- Department of Neurological Surgery, University of California, 505 Parnassus Ave, 94143 0112, San Francisco, CA, USA.
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32
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Kim JW, Kim BM, Park KY, Kim DJ, Kim DI. Onyx Embolization for Isolated Type Dural Arteriovenous Fistula Using a Dual-Lumen Balloon Catheter. Neurosurgery 2016; 78:627-36. [DOI: 10.1227/neu.0000000000001069] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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33
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Leyon JJ, Chavda S, Thomas A, Lamin S. Preliminary experience with the liquid embolic material agent PHIL (Precipitating Hydrophobic Injectable Liquid) in treating cranial and spinal dural arteriovenous fistulas: technical note. J Neurointerv Surg 2015; 8:596-602. [PMID: 25994938 DOI: 10.1136/neurintsurg-2015-011684] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 05/04/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Liquid embolic agents are the preferred embolic material in endovascular treatment of pial and brain arteriovenous malformations and dural arteriovenous fistulas (DAVFs). There is little choice available in interventional neuroradiology practice other than two of the most commonly used liquid embolic agents-n-butyl cyanoacrylate and the Onyx liquid embolic system (ev3 Neurovascular, Irvine, California, USA). PHIL (Precipitating Hydrophobic Injectable Liquid) (Microvention, Inc California, USA) is a new liquid embolic agent, CE marked and available for clinical use in Europe. OBJECTIVE To present our preliminary experience using PHIL in treating cranial and spinal DAVFs. METHODS Between September 2014 and January 2015, eight patients, with five cranial DAVFs and three spinal DAVFs were treated with PHIL as the sole embolic agent used with intent to cure. Clinical presentation, location of DAVF, Borden type, fluoroscopic time, radiation dose, procedural time, injecting microcatheter used, volume of PHIL injected, complications, immediate angiographic data, premorbid and discharge modified Rankin Scale score, and any neurologic deficits were included in the analysis. RESULTS Seven patients were successfully treated with complete angiographic exclusion of the fistula in a single sitting. Treatment failed in one patient where only suboptimal microcatheter positioning could be achieved and PHIL failed to penetrate the fistula's nidus. Venous penetration was achieved in all other patients except one with a small fistula, but with adequate fistula penetration by the embolic material. No other technical complication or neurologic deterioration occurred in any of the patients. CONCLUSIONS PHIL liquid embolic agent appears to be an excellent alternative embolic material with certain advantages compared with other available liquid embolic agents. Further studies are required to fully evaluate its safety and efficacy.
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Affiliation(s)
- Joe J Leyon
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Swarupsinh Chavda
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Allan Thomas
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Saleh Lamin
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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34
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Borota L, Mahmoud E, Nyberg C, Ekberg T. Combined percutaneous and transarterial devascularisation of juvenile nasopharyngeal angiofibroma with protection of internal carotid artery: A modification of the technique. Interv Neuroradiol 2015; 21:390-6. [PMID: 25991005 DOI: 10.1177/1591019915581988] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Juvenile nasal angiofibroma (JNA) is a hypervascularised, benign, but locally aggressive tumour that grows in the posterior, upper part of the nasal cavity and invades surrounding anatomical structures. The treatment of choice is surgical removal, but complete resection of the tumour can be hampered because of profuse perioperative bleeding. Preoperative embolisation of the tumour has been proposed as an effective method for prevention of perioperative bleeding, thereby shortening of the time of the operation. In this report of five cases, we describe successful preoperative devascularisation of the tumour by applying a modified method of direct intratumoural injection of the liquid embolic agent Onyx combined with protection of the internal carotid artery. The control of bleeding during the embolisation and occlusion of the maxillary or sphenopalatine artery was achieved by using a bi-luminal balloon catheter. Such use of the dual-lumen catheter in treatment of JNA has not been reported so far in the medical literature.
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Affiliation(s)
- Ljubisa Borota
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Ehab Mahmoud
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Christoffer Nyberg
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Tomas Ekberg
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
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Gentric JC, Raymond J, Batista A, Salazkin I, Gevry G, Darsaut TE. Dual-lumen balloon catheters may improve liquid embolization of vascular malformations: an experimental study in Swine. AJNR Am J Neuroradiol 2015; 36:977-81. [PMID: 25593200 DOI: 10.3174/ajnr.a4211] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/06/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Liquid embolic agents are increasingly used to treat vascular malformations. We sought to assess embolization with these agents by using a dual-lumen balloon catheter in an experimental setting. MATERIALS AND METHODS Eighteen injections of liquid embolic agents were performed in the rete mirabile of swine. We used 3 methods to control liquid embolic agent reflux: 1) dual-lumen balloon-catheter (group A, n = 8); 2) injection of liquid embolic agent after proximal n-BCA plug formation through a second microcatheter (group B, n = 4); and 3) standard liquid embolic agent injection (group C, controls, n = 6). The following outcomes were graded by using ordinal scales by angiography, macrophotography, and radiography of retia after euthanasia: 1) angiographic and pathologic extent of liquid embolic agent embolization of the rete, 2) reflux of liquid embolic agents in the parent artery, and 3) density of liquid embolic agents in the proximal rete. Technical complications were also recorded. A successful injection was defined as an embolization that reached the contralateral rete without reflux into proximal external branches. Exact logistic regression analyses were performed to compare groups. RESULTS There were significant differences among groups for reflux (P = .029) and liquid embolic agent density in the proximal rete (P = .014), while extension to the contralateral rete did not reach statistical significance (P = .07). Injections differed among groups (P = .004), with dual-lumen balloon-catheter injections more frequently successful compared with control injections (P = .019). CONCLUSIONS Dual-lumen balloon catheters allowed better liquid embolic agent injections than standard injections.
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Affiliation(s)
- J C Gentric
- From the Department of Radiology (J.C.G., J.R., A.B.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada Equipe d'Accueil 3878 - Groupe d'Etude de la Thrombose en Bretagne Occidentale (J.C.G.), Université de Bretagne Occidentale, Brest, France
| | - J Raymond
- From the Department of Radiology (J.C.G., J.R., A.B.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada Laboratory of Interventional Neuroradiology (J.R., I.S., G.G.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada
| | - A Batista
- From the Department of Radiology (J.C.G., J.R., A.B.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - I Salazkin
- Laboratory of Interventional Neuroradiology (J.R., I.S., G.G.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada
| | - G Gevry
- Laboratory of Interventional Neuroradiology (J.R., I.S., G.G.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada
| | - T E Darsaut
- Division of Neurosurgery (T.E.D.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Flow control using Scepter™ balloons for Onyx embolization of a vein of Galen aneurysmal malformation. Childs Nerv Syst 2015; 31:135-40. [PMID: 25358810 DOI: 10.1007/s00381-014-2576-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/20/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE We present a technical development of the endovascular treatment technique for vein of Galen aneurysmal malformation, using Onyx™ (ethylene vinyl alcohol copolymer) delivered under flow control through double-lumen balloon microcatheters. MATERIALS AND METHODS An 11-month-old patient that initially presented with increasing head circumference was diagnosed with mural type vein of Galen aneurysmal malformation. Complete cure was obtained in a single endovascular treatment session. Onyx was delivered simultaneously through two double-lumen balloon microcatheters (Scepter™, Microvention, Terumo Group). In both arterial feeders, balloon inflation occluded the high-flow arterial-venous shunting and thus facilitated the controlled propagation of the embolic product in the afferent artery and the shunt point while preventing distal migration into the venous system. RESULTS Two years post-procedure, MR imaging showed persistent occlusion of arterial-venous shunts with complete regression of the venous dilatation. On clinical examination, the patient had no neurological deficits, and no cognitive impairment was detected at neuropsychological testing. CONCLUSION The use of double-lumen balloon microcatheters for flow control during delivery of Onyx represents a viable alternative for the endovascular treatment of vein of Galen aneurysmal malformations.
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Spiotta AM, James RF, Lowe SR, Vargas J, Turk AS, Chaudry MI, Bhalla T, Janjua RM, Delaney JJ, Quintero-Wolfe S, Turner RD. Balloon-augmented Onyx embolization of cerebral arteriovenous malformations using a dual-lumen balloon: a multicenter experience. J Neurointerv Surg 2014; 7:721-7. [PMID: 25118193 DOI: 10.1136/neurintsurg-2014-011285] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 07/22/2014] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Conventional Onyx embolization of cerebral arteriovenous malformations (AVMs) requires lengthy procedure and fluoroscopy times to form an adequate 'proximal plug' which allows forward nidal penetration while preventing reflux and non-targeted embolization. We review our experience with balloon-augmented Onyx embolization of cerebral AVMs using a dual-lumen balloon catheter technique designed to minimize these challenges. METHODS Retrospectively acquired data for all balloon-augmented cerebral AVM embolizations performed between 2011 and 2014 were obtained from four tertiary care centers. For each procedure, at least one Scepter C balloon catheter was advanced into the AVM arterial pedicle of interest and Onyx embolization was performed through the inner lumen after balloon inflation via the outer lumen. RESULTS Twenty patients underwent embolization with the balloon-augmented technique over 24 discreet treatment episodes. There were 37 total arterial pedicles embolized with the balloon-augmented technique, a mean of 1.9 per patient (range 1-5). The treated AVMs were heterogeneous in their location and size (mean 3.3±1.6 cm). Mean fluoroscopy time for each procedure was 48±26 min (28 min per embolized pedicle). Two Scepter C balloon catheter-related complications (8.3% of embolization sessions, 5.4% of pedicles embolized) were observed: an intraprocedural rupture of a feeding pedicle and fracture and retention of a catheter fragment. CONCLUSIONS This multicenter experience represents the largest reported series of balloon-augmented Onyx embolization of cerebral AVMs. The technique appears safe and effective in the treatment of AVMs, allowing more efficient and controlled injection of Onyx with a decreased risk of reflux and decreased fluoroscopy times.
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Affiliation(s)
- Alejandro M Spiotta
- Division of Neurosurgery, Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert F James
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA Division of Neurosurgery, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Stephen R Lowe
- Division of Neurosurgery, Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jan Vargas
- Division of Neurosurgery, Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aquilla S Turk
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - M Imran Chaudry
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tarun Bhalla
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Rashid M Janjua
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - John J Delaney
- Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Stacey Quintero-Wolfe
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Raymond D Turner
- Division of Neurosurgery, Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
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