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Meyers PM, Fifi JT, Cockroft KM, Miller TR, Given CA, Zomorodi AR, Jagadeesan BD, Mokin M, Kan P, Yao TL, Diaz O, Huddle D, Bellon RJ, Seinfeld J, Polifka AJ, Fiorella D, Chitale RV, Kvamme P, Morrow JT, Singer J, Wakhloo AK, Puri AS, Deshmukh VR, Hanel RA, Gonzalez LF, Woo HH, Aziz-Sultan MA. Safety of the APOLLO Onyx delivery microcatheter for embolization of brain arteriovenous malformations: results from a prospective post-market study. J Neurointerv Surg 2021; 13:935-941. [PMID: 33526480 DOI: 10.1136/neurintsurg-2020-016830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/18/2020] [Accepted: 11/21/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Catheter retention and difficulty in retrieval have been observed during embolization of brain arteriovenous malformations (bAVMs) with the Onyx liquid embolic system (Onyx). The Apollo Onyx delivery microcatheter (Apollo) is a single lumen catheter designed for controlled delivery of Onyx into the neurovasculature, with a detachable distal tip to aid catheter retrieval. This study evaluates the safety of the Apollo for delivery of Onyx during embolization of bAVMs. METHODS This was a prospective, non-randomized, single-arm, multicenter, post-market study of patients with a bAVM who underwent Onyx embolization with the Apollo between May 2015 and February 2018. The primary endpoint was any catheter-related adverse event (AE) at 30 days, such as unintentional tip detachment or malfunction with clinical sequelae, or retained catheter. Procedure-related AEs (untoward medical occurrence, disease, injury, or clinical signs) and serious AEs (life threatening illness or injury, permanent physiological impairment, hospitalization, or requiring intervention) were also recorded. RESULTS A total of 112 patients were enrolled (mean age 44.1±17.6 years, 56.3% men), and 201 Apollo devices were used in 142 embolization procedures. The mean Spetzler-Martin grade was 2.38. The primary endpoint was not observed (0/112, 0%). The catheter tip detached during 83 (58.5%) procedures, of which 2 (2.4%) were unintentional and did not result in clinical sequelae. At 30 days, procedure related AEs occurred in 26 (23.2%) patients, and procedure-related serious AEs in 12 (10.7%). At 12 months, there were 3 (2.7%) mortalities, including 2 (1.8%) neurological deaths, none of which were device-related. CONCLUSION This study demonstrates the safety of Apollo for Onyx embolization of bAVMs. CLINICAL TRIAL REGISTRATION CNCT02378883.
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Affiliation(s)
- Philip M Meyers
- Departments of Radiology and Neurological Surgery, Columbia University, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Timothy R Miller
- Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Curtis A Given
- Department of Radiology, Baptist Health Lexington, Lexington, Kentucky, USA
| | - Ali R Zomorodi
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Bharathi D Jagadeesan
- Department of Radiology, Neurosurgery and Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Tom L Yao
- Department of Neurosurgery, Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Orlando Diaz
- Division of Interventional Neuroradiology, Houston Methodist Hospital, Houston, Texas, USA
| | - Daniel Huddle
- Department of Brain, Spine, Physical Medicine and Rehabilitation, UC Health Medical Group (UCHMG), Colorado Springs, Colorado, USA
| | - Richard J Bellon
- Department of Neurology, Swedish Medical Center, Englewood, Colorado, USA
| | - Joshua Seinfeld
- Department of Neurosurgery and Radiology, University of Colorado Medical Center, Aurora, Colorado, USA
| | - Adam J Polifka
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - David Fiorella
- Department of Neurosurgery, Cerebrovascular Center, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Rohan V Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter Kvamme
- Department of Radiology, The University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Jay T Morrow
- Neuroscience Institute, Division of Neurosurgery, Michigan State University, Spectrum Health, Grand Rapids, Michigan, USA
| | - Justin Singer
- Neuroscience Institute, Division of Neurosurgery, Michigan State University, Spectrum Health, Grand Rapids, Michigan, USA
| | - Ajay K Wakhloo
- Department of Neurointerventional Radiology, Beth Israel Lahey Health, Tufts School of Medicine, Burlington, Massachusetts, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | | | - Ricardo A Hanel
- Baptist Health Research Institute, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | | | - Henry H Woo
- Department of Neurosurgery and Radiology, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Qureshi AI, Mian N, Siddiqi H, Qureshi MH, Malik AM, Rauf Afzal M, Khan AA, Suri MFK. Occurrence and Management Strategies for Catheter Entrapment with Onyx Liquid Embolization. J Vasc Interv Neurol 2015; 8:37-41. [PMID: 26301030 PMCID: PMC4535605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In June 2012, Food and Drug Administration (FDA) issued a warning about the risk of catheter entrapment associated with Onyx embolization. We used our experience, literature review, and FDA Manufacturer and User Facility Device Experience (MAUDE) data review to identify five strategies to address catheter entrapment: 1/. Surgical resection of vessel at point of entrapment of catheter and retraction from exterior portion at the femoral region; 2/. Advancing and closing the loop of snare over the entrapped catheter followed by retraction; 3/. Advancing the distal access catheter over the entrapped catheter and retraction with forward movement of the distal access catheters; 4/. Inflation of balloon catheter coaxial to the entrapped catheter with subsequent retraction; and 5/. Intravascular retention and internalization of microcatheter. In the MAUDE data, there were 77 reports of catheter entrapment with Onyx embolization; microcatheter was retracted by surgical excision in 15, endovascular snare or other retriever devices in 5, deliberately entrapped inside the vessel using stent in 1, and left without intervention within intravascular compartment in 27 patients.
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Affiliation(s)
| | | | | | | | - Adil M Malik
- Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA
| | | | - Asif A Khan
- Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA
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7
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Herial NA, Khan AA, Suri MFK, Sherr GT, Qureshi AI. Liquid embolization of brain arteriovenous malformation using novel detachable tip micro catheter: a technical report. J Vasc Interv Neurol 2014; 7:64-68. [PMID: 25566344 PMCID: PMC4280868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND IMPORTANCE Liquid embolization using Onyx® of brain arteriovenous malformations (AVMs) is sometimes limited by micro catheter retention by Onyx® cast during the disengagement process. Use of the new detachable tip micro catheter is presented in this report. CLINICAL PRESENTATION Two feeding arteries of a previously ruptured brain AVM in a 62-year-old man were embolized by Onyx 18 prior to surgery using the new Apollo™ micro catheter with the detachable-tip (30 mm) was utilized. The arterial feeders were accessed without difficulty by micro catheter, guided by 0.010" microwire. Onyx reflux around the distal end of the micro catheter was necessary for effective embolization of arteriovenous fistulous components of brain AVM. The micro catheter was successfully retracted after embolization in both feeding arteries, with distal end detachment seen in one but not the other arterial embolization. No arterial thrombosis, vasospasm, dissection, or rupture was seen at respective sites of disengagement. CONCLUSION Use of the new micro catheters with detachable-tip design allowed prolonged Onyx® injection times, safe micro catheter disengagement, without any limitations in accessing target arterial feeders.
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Affiliation(s)
| | | | | | | | - Adnan I Qureshi
- Correspondence to: Adnan I Qureshi, Zeenat Qureshi Stroke Institute, 519 2nd Street N, St Cloud, MN 56303, USA,
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8
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Gao X, Liang G, Li Z, Wang X, Yu C, Cao P, Chen J, Li J. Transarterial coil-augmented Onyx embolization for brain arteriovenous malformation. Technique and experience in 22 consecutive patients. Interv Neuroradiol 2014; 20:83-90. [PMID: 24556304 DOI: 10.15274/inr-2014-10012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 09/22/2013] [Indexed: 11/12/2022] Open
Abstract
Onyx has been widely adopted for the treatment of arteriovenous malformations (AVMs). However, its control demands operators accumulate a considerable learning curve. We describe our initial experience using a novel injection method for the embolization of AVMs. We retrospectively reviewed the data of all 22 patients with brain AVMs (12 men, 10 women; age range, 12-68 years; mean age, 43.2 years) treated by the transarterial coil-augmented Onyx injection technique. The size of the AVMs ranged from 25 mm to 70 mm (average 35.6 mm). The technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated. In every case, endovascular treatment (EVT) was completed. A total of 31 sessions were performed, with a mean injection volume of 6.1 mL (range, 1.5-16.0 mL). An average of 96.7% (range 85%-100%) estimated size reduction was achieved, and 18 AVMs could be completely excluded by EVT alone. The results remained stable on follow-up angiograms. A procedural complication occurred in one patient, with permanent mild neurologic deficit. Our preliminary series demonstrated that the coil-augmented Onyx injection technique is a valuable adjunct achieving excellent nidal penetration and improving the safety of the procedure.
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Affiliation(s)
- Xu Gao
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China -
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China
| | - Zhiqing Li
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China
| | - Xiaogang Wang
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China
| | - Chunyong Yu
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China
| | - Peng Cao
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China
| | - Jun Chen
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China
| | - Jingyuan Li
- Department of Neurosurgery, General Hospital of Shenyang Military Command; Shenyang, China
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Losey AD, Lillaney P, Martin AJ, Halbach VV, Cooke DL, Dowd CF, Higashida RT, Saloner DA, Wilson MW, Saeed M, Hetts SW. Safety of retained microcatheters: an evaluation of radiofrequency heating in endovascular microcatheters with nitinol, tungsten, and polyetheretherketone braiding at 1.5 T and 3 T. J Neurointerv Surg 2013; 6:314-9. [PMID: 23685793 DOI: 10.1136/neurintsurg-2013-010746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The use of ethylene-vinyl alcohol copolymer for liquid embolization of cranial vascular lesions has resulted in microcatheter fragments entrapped in patients following endovascular procedures. Undergoing subsequent diagnostic MRI examinations poses a safety concern due to the possibility of radiofrequency heating of the metallic braid incorporated into the microcatheter. Heating of nitinol, tungsten, and polyetheretherketone (PEEK) braided microcatheters was assessed and compared using a phantom model. METHODS Microcatheters coupled with fluoroptic temperature probes were embedded in a polyacrylamide gel within a head and torso phantom. Experiments were performed at 1.5 T and 3 T, analyzing the effects of different catheter immersion lengths, specific absorption rate (SAR) levels, short clinical scans, long clinical scans, and microcatheter fragment lengths. RESULTS The maximal increase in temperature for the nitinol braided microcatheter during a 15 min scan was 3.06°C using the T1 fast spin echo sequence at 1.5 T and 0.45°C using the balanced steady state free precession sequence at 3 T. The same scans for fragment lengths of 9, 18, 36, and 72 cm produced maximal temperature rises of 0.68, 0.80, 1.70, and 1.07°C at 1.5 T, respectively. The temperature changes at 3 T for these fragment lengths were 0.66, 0.83, 1.07, and 0.72°C, respectively. The tungsten and PEEK braided microcatheters did not demonstrate heating. CONCLUSIONS Substantial heating of nitinol braided microcatheters occurred and was a function of SAR level and geometric considerations. SAR and time limitations on MR scanning are proposed for patients with this microcatheter entrapped in their vasculature. In contrast, tungsten and PEEK braided microcatheters showed potential safe use in MRI.
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Affiliation(s)
- Aaron D Losey
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
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