Economic analysis of n-butyl cyanoacrylate compared with ethylene vinyl alcohol copolymer liquid embolic embolization of brain arteriovenous malformations (bAVMs) from a US hospital perspective

BACKGROUND

In US hospitals, the liquid embolic systems (LESs) n-butyl cyanoacrylate (n-BCA) and ethylene vinyl alcohol copolymer (EVOH) are used for brain arteriovenous malformation (bAVM) embolization to achieve presurgical devascularization. The aim of this study was to perform an economic analysis comparing four techniques for bAVM embolization based on LES, ancillary device, and angiography suite time costs.

METHODS

An economic model was developed comparing the embolization costs for n-BCA, EVOH with the plug and push technique, EVOH with detachable-tip microcatheters, and EVOH with balloon microcatheters. Per procedure costs were calculated for bAVMs with one to four pedicles. Annual cohort analyses were performed to evaluate the potential impact for low and high-volume centers. Sensitivity analyses were performed to determine cost drivers.

RESULTS

The analyses showed that the n-BCA technique was the least costly of the four techniques. Total per procedure costs for one to four embolized pedicles ranged from $5941 to $10,074 for the n-BCA technique, $8428 to $30,345 for the EVOH balloon microcatheter technique, $12,711 to $47,477 for the EVOH plug and push technique, and $13,900 to $52,233 for the EVOH detachable-tip microcatheter technique. Cohort analyses costs for 52 annual cases ranged from $308,953 to $523,838 with the n-BCA technique and from $722,816 to $2,716,096 with the EVOH detachable-tip microcatheter technique.

CONCLUSIONS

Procedure costs associated with n-BCA are lower than those with each of the three EVOH techniques examined. Future cost analyses should compare the costs of new LES products once available.

Initial experience with the Scepter Mini catheter for the embolization of vascular malformations in the pediatric population

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.

Galenic dural arteriovenous fistula in neurofibromatosis type 1 treated with Onyx

Galenic dural arteriovenous fistula (GDAVF) represents a unique, hard-to-treat subgroup of tentorial dural arteriovenous fistulae. Neurofibromatosis type 1 (NF1) has been infrequently associated with different cerebrovascular conditions that may lead to either ischemic or haemorrhagic stroke. Intracranial GDAVF has not been described in NF1 patients. We present an unusual case of GDAVF in a 37-year-old man with NF1. The fistula drained directly to the vein of Galen through multiple feeders. Complete occlusion of the fistula was achieved through trans-arterial embolisation with Onyx (ethylene vinyl alcohol copolymer) in a single treatment session. Deep venous drainage remained intact, and the patient recovered well. To our knowledge, this is the first report on complete closure of GDAVF with NF1 using trans-arterial embolisation. The preservation of functioning of the straight sinus may have contributed to the success of treatment.

Endovascular treatment of intracranial arteriovenous malformations using detachable-tip microcatheters and Onyx 18®

PURPOSE

To evaluate clinical and imaging features before embolization, data of embolization procedure and outcome in patients with ruptured or unruptured intracranial arteriovenous malformation (AVM) who were treated by endovascular embolization using detachable-tip microcatheters and Onyx 18^®.

MATERIAL AND METHODS

Forty-three patients treated with endovascular embolization using a detachable-tip microcatheter and Onyx18^® between January 2008 and April 2016 were evaluated. There were 27 men and 16 women with a mean age of 35.9±14.1years (range: 10-68years). Clinical and imaging features, embolization details and post-treatment findings were analyzed. Patients were divided into ruptured AVM and unruptured AVM groups. Death, complications and total embolization rates of each group were assessed.

RESULTS

Fifty-one embolization sessions were performed in 43 patients. Total embolization rate was 40% (17/43). There were significant relationships between AVM diameter and total embolization success and AVM diameter and complication rates. The degree of embolization was partial in all patients who had complications. Catheter retention and iatrogenic rupture were not observed in any procedure. No major neurologic deficit was seen in patients who had unruptured AVM and complications after treatment.

CONCLUSIONS

Our results show the efficacy of endovascular embolization of AVM using detachable-tip microcatheters and Onyx 18^®. A new AVM classification system based on AVM diameter for this embolization technique may be more predictive in terms of total embolization success and complication development.