Percutaneous n-butyl cyanoacrylate embolization of cervical metastatic disease via an anterolateral approach.

Symptomatic vascular spinal metastases will benefit from pre-operative tumor embolization - percutaneous with or without adjunct endovascular embolization. However, when a transpedicular approach is not feasible, an anterolateral approach may be a viable alternative. The authors report a 57-year-old woman with prior C3-T1 instrumentation who presented with acute cord compression from a pathologic C5 vertebral body fracture related to metastatic renal cell carcinoma. The patient underwent CT-guided direct tumor embolization with 33% n-butyl-2-cyanoacrylate via an anterolateral approach, followed by C5-corpectomy and anterior cervical C4-C6 fusion and plating with minimal blood loss (est. 20 cc) and a stable neurological exam post-operatively. In patients with highly vascular cervical metastatic disease who lack a viable transpedicular approach for preoperative tumor embolization, a CT-guided anterolateral approach is a viable alternative.

Management of scalp arteriovenous malformations: a rising trend towards percutaneous direct puncture embolization technique-our experience.

BACKGROUND: Scalp arteriovenous malformations (AVMs), or cirsoid aneurysms of the scalp, usually present with troublesome symptoms and cosmetic disfigurement. Endovascular/percutaneous embolization has evolved as a sole treatment method or adjunct to surgical excision in the management of scalp AVMs with an excellent outcome. PURPOSE: To discuss minimally invasive techniques for treating scalp AVMs as well as to highlight the role of embolization before surgery. MATERIAL AND METHODS: This is a retrospective study of 50 patients with scalp AVM who underwent embolization (percutaneous/endovascular) during 2010-2019 at a tertiary care center. n-butyl cyanoacrylate (n-BCA) was used as an embolizing agent in all the cases and the patients were followed up at three- and six-month intervals with Doppler evaluation. RESULTS: A total of 50 patients were included in the study. The occipital region was the most common location; 82% were Schobinger class II lesions and 18% were class III lesions. Thirteen patients had small-sized AVMs and 37 patients had large-sized AVMs. Post-embolization surgery was performed in 36 patients. Of the patients, 28 underwent percutaneous embolization, 20 underwent endovascular embolization, and two underwent both to achieve complete embolization of the lesion. The number of percutaneous procedures increased in the latter half of the study period as the safety and efficacy of the technique were established. No major complications were seen in this study. CONCLUSION: Embolization of scalp AVMs is a safe and effective technique and can be used in isolation for small lesions and as an adjunct procedure to surgery for large-sized lesions.

Preoperative n-BCA embolization in the resection of submandibular lymphatic malformations refractory to sclerotherapy treatment: A pilot case series.

OBJECTIVE: Lymphatic malformations in the submandibular neck pose unique challenges to treatment that elevate their risk of recurrence. This case series provides a review of five patients, previously treated with sclerotherapy or with a history of multiple infections, who were treated in a novel fashion: single-stage resection using preoperative n-butyl cyanoacrylate (n-BCA) glue embolization. METHODS: We performed a retrospective medical record review of five patients who underwent single-stage n-BCA embolization by Interventional Radiology followed by surgical resection by Otolaryngology, including a review of their symptoms, previous treatments, and post-treatment surveillance, with follow-up ranging from 4 to 24 months after the treatment of interest. RESULTS: All study subjects had unremarkable perioperative courses, and four patients did not demonstrate any evidence of disease recurrence or persistence during the follow-up period. One patient was found to have a small area of persistent disease on post-treatment imaging, but has remained symptom free. CONCLUSIONS: Treatment of submandibular lymphatic malformations with n-BCA embolization followed by surgical resection can be performed in a single stage. This case series demonstrates that this approach can yield durable relief of symptoms, even in patients whose lesions were refractory to previous treatments.

Hepatic Arterioportal Fistula in Patients with Cirrhosis with Endovascular Management-A Series of 4 Cases with Review of Literature.

Hepatic arterioportal fistula (APF) in the setting of cirrhosis may aggravate the preexisting portal hypertension and its complications. Cirrhotic patients undergo various percutaneous invasive procedures and are at risk of developing an APF. These should be diagnosed early and should be treated accordingly at the earliest when indicated. Presently embolization is the treatment of choice with coil embolization as the most commonly used method. We describe four cases from our institute with a history of liver parenchymal disease and were found to have acquired APF on imaging. These were successfully managed with transarterial embolization with resolution or improvement in their clinical symptoms on follow-up. The present case series and review emphasize the importance of APF in the setting of liver parenchymal disease and the role of early diagnosis and therapeutic intravascular interventions.

Comparison of transarterial n-BCA and Onyx embolization of brain arteriovenous malformations: A single-center 18-year retrospective analysis.

OBJECTIVE: Brain arteriovenous malformations (AVM) are commonly treated with endovascular embolization. Due to the rapid evolution of endovascular technology and lack of consistent practice guidelines regarding AVM embolization, further study of AVM embolization outcomes is warranted. METHODS: We conducted a retrospective review of AVMs embolized at a single center from 2002-2019. Patient demographics, AVM characteristics, intention of embolization, and angiographic and clinical outcome after embolization were recorded. We compared the embolization results of those treated with n-butyl cyanoacrylate (n-BCA) and Onyx. RESULTS: Over an 18-year period at our institution, 30 (33%) of 92 AVMs were treated with embolization. n-BCA was used in 12 cases and Onyx in 18 cases. Eighty-seven pedicles were embolized over 47 embolization sessions. Fifty percent of AVMs treated with n-BCA underwent more than one embolization session compared to 22% when Onyx was used. The median total percent volume reduction in the n-BCA AVMs was 52% compared to 51% in Onyx AVMs. There were 2 periprocedural complications in the n-BCA cohort and none in the Onyx cohort. CONCLUSIONS: In this small retrospective series, Onyx and n-BCA achieved similar occlusion results, although n-BCA required more sessions and pedicles embolized to do so.

Combined endolymphatic and surgical treatment of a leaking central conducting lymphatic malformation in a neonate.

Lymphatic malformations are congenital alterations of normal embryonic lymphatic development. We present a case of a premature 7-week-old male with a large central conducting lymphatic malformation and significant abdominal chylorrhea. He was successfully treated with combined endolymphatic and surgical approaches. To the authors' knowledge, this is the first case to be described.

Comparison of Cost and Efficacy of Trufill® vs Histoacryl® n-Butyl Cyanoacrylate for Translumbar Type 2 Endoleak Embolization.

PURPOSE: The study aimed to compare the cost and efficacy of translumbar approach type 2 endoleak repairs using either Trufill® or Histoacryl® n-BCA liquid embolic. METHOD AND MATERIALS: This was a retrospective review of patients who had translumbar approach type 2 endoleak repairs using either Trufill® or Histoacryl®. Patients were included if they underwent a technically successful type 2 endoleak repair via a translumbar approach with Trufill® or Histoacryl® n-BCA. A multivariable analysis was performed with the primary clinical outcome of percent change in aneurysm diameter per month compared. Procedure cost was calculated based on typical materials used. RESULTS: 20 Trufill® and 14 Histoacryl® patients were included. The mean procedure cost was higher for Trufill® ($5,757.30 vs. $1,586.09, p ≤ 0.001). There was no significant difference between Trufill® or Histoacryl® patients for age at first embolization, gender, total number of embolizations, number of feeding branches, aneurysm sac size prior to embolization, or residual endoleak at first follow-up. Trufill® patients had more coils used (12.0 vs. 4.3, p = 0.0007), less glue used (0.9 vs. 2.1 mL, p < 0.001), longer follow-up duration (33.5 vs. 13.2 months, p = 0.002), more follow-up CT angiograms (CTA) (3.7 vs. 1.9, p = 0.01), and larger excluded aneurysm sac size at most recent CTA (7.1 cm vs. 5.9 cm, p = 0.04). Percent change in sac diameter per month was not significantly different between Trufill® and Histoacryl® (0.21% vs. -0.25%/month, p = 0.06, respectively). There were no complications. CONCLUSION: Use of Histoacryl® over Trufill® n-BCA resulted in significantly less procedural cost while maintaining safety and efficacy.

Utilizing immediate preoperative n-BCA in the resection of head and neck venous and lymphatic malformations.

PURPOSE/OBJECTIVE: To add to the current literature on single stage excision of head and neck vascular malformations with preoperative n-butyl cyanoacrylate (n-BCA) glue. Unlike previous studies, this series includes pediatric and adult patients, highlights a single stage partial excision of a complex venous malformation, and describes the first description of using glue prior to resection of a macrocystic lymphatic malformation. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care adult and pediatric hospital. SUBJECTS AND RESULTS: Four patients (3 males - 9, 13, 25 years, 1 female - 61 years) underwent same day excision of head and neck vascular malformations utilizing immediate preoperative n-BCA glue embolization performed by interventional radiology and otolaryngology, as described by Tieu et al. The indications for resection included bleeding (1/4), pain (3/4), cosmetic deformity (3/4), and discomfort with denture wear (1/4). Prior interventions included none (1/4), cautery and primary closure to control acute hemorrhage (1/4), and sclerotherapy (2/4). Treatments included complete embolization and resection of simple venous malformation (VM)s of the oral cavity/lip (2/4), partial embolization and resection of a complex hemifacial venous malformation (VM) (1/4), and complete embolization and resection of a lymphatic malformation (LM) (1/4). On average, 97 min of anesthesia time was added for the preoperative embolization procedure (range, 94-104 min). All patients had a successful embolization without need for coils. Operative time ranged from 28 to 44 min for the simple cases and was 6 h and 30 min for the complex case. There was minimal blood loss in all cases. There were no associated complications, lesion recurrences, or long-term deficits at an average follow-up of 5 months. The patient with the complex hemifacial VM demonstrated subtle lower facial weakness post-operatively, which completely resolved within two months. CONCLUSIONS: Treatment of head and neck vascular malformations with preoperative n-BCA glue and subsequent surgical excision is a viable method for both simple and complex lesions. The safety and efficacy of this technique has been demonstrated in the past in a limited number of studies. This study further supports the use of this technique to address patient concerns such as pain or discomfort and cosmetic deformity, even if the lesion is only partially resectable. In our series a lymphatic malformation refractory to sclerotherapy was treated with a similar technique of glue and resection, following aspiration of the mucoid LM fluid. Our series emphasizes that pediatric vascular malformations carry functional and cosmetic deficits into adulthood that can and should be addressed in this patient population. Therefore, same-day embolization and resection should be coordinated when possible, in order to optimize patient safety and convenience.

Endolymphatic exclusion for the treatment of pediatric chylous ascites secondary to neuroblastoma resection: report of two cases.

Chylous ascites is a rare, but highly morbid complication of oncologic resection, often associated with retroperitoneal lymphadenectomy. Conservative measures with total parenteral nutrition or lipid-reduced formulas constitute the initial mainstay therapy, but not without risks and failures. This report describes 2 endolymphatic treatment strategies for iatrogenic chylous ascites following neuroblastoma resection. Lymphatic leaks were identified using intranodal lymphangiography, targeted with cone-beam computed tomographic guidance, and embolized with n-butyl cyanoacrylate. There were no adverse outcomes, with complete resolution of chylous ascites and a mean follow-up of 26 months.

Angioembolization of Post-traumatic Intrahepatic Arterioportal Fistula Presenting With Portal Hypertension.

Traumatic hepatic arterioportal fistula is an abnormal communication between the hepatic artery and portal vein and is a rare cause of non-cirrhotic portal hypertension with delayed presentation, usually after a remote history of abdominal trauma or an interventional procedure. This case report is of one such rare presentation, wherein a 59-year-old gentleman presented with unexplained ascites and complications of portal hypertension, eventually diagnosed with an arterioportal fistula on a computed tomography scan and managed by angioembolization. There was a remarkable improvement in the complications of portal hypertension after the coil embolization.

Results of Endovascular-First Approach for Treatment of Scalp Arteriovenous Malformations and the Effect of Simplified Angiographic Classification in Therapeutic Decision-Making and Outcomes.

BACKGROUND: Scalp arteriovenous malformation (SAVM) is primarily treated by surgery and reports on endovascular treatment are scarce. We report the results of an endovascular-first approach in the treatment of SAVM. We also have proposed a simple dichotomized classification using the angiographically determined morphology findings and discussed its effect on therapeutic decision-making and outcomes. METHODS: A consecutive series of 25 patients with SAVM treated by initial or endovascular-only methods were included in the final analysis. The SAVM was categorized as a plexiform or fistulous type according to the angiographic morphology. The demographic data, treatment variables, and final clinical outcomes were analyzed and correlated with the proposed classification. RESULTS: Of the 25 patients, 21 were treated with n-butyl cyanoacrylate (n-BCA) and 3 with liquid ethylene vinyl alcohol. One patient had been treated initially with polyvinyl alcohol particles and later with n-BCA. Overall, complete or near complete obliteration (>90%) was achieved in 72%. Surgical excision was performed in 76%, most often after n-BCA embolization. Fistulous-type SAVMs required greater n-BCA concentrations (median, 33% vs. 20%; P = 0.024) and achieved greater rates of complete or near-complete obliteration (90% vs. 63%). Two patients with fistulous-type SAVMs treated with liquid ethylene vinyl alcohol showed complete resolution, and further treatment was not necessary. Overall, regardless of the embolic material used, the fistulous type demonstrated a significantly greater rate of complete obliteration (75% vs. 33%; P = 0.041) compared with plexiform type. CONCLUSION: High rates of complete and durable obliteration of SAVM are achievable with endovascular embolization. The proposed simplified classification is easy to implement and can aid in choosing the appropriate embolic agent and predicting the therapeutic outcome.

Rapid cardiac ventricular pacing to facilitate embolization of vein of Galen malformations: technical note.

In BriefBabies born with life-threatening brain blood-vessel malformations can be helped with new heart pacemaker technology to temporarily stop the flow of blood in their bodies during surgery, for inducing hypotension to aid in controlled embolization.

The Meningioma Vascularity Index: a volumetric analysis of flow voids to predict intraoperative blood loss in nonembolized meningiomas.

OBJECTIVEMeningiomas that appear hypervascular on neuroimaging could be amenable to preoperative embolization. However, methods for measuring hypervascularity have not been described, nor has the benefit of preoperative embolization been adjudicated. The objective of this study was to show a relationship between flow void volume (measured on MRI) and intraoperative estimated blood loss (EBL) in nonembolized meningiomas.METHODSThe authors performed volumetric analyses of 51 intracranial meningiomas (21 preoperatively embolized) resected at their institution. Through the use of image segmentation software and a voxel-based segmentation method, flow void volumes were measured on T2-weighted MR images. This metric was named the Meningioma Vascularity Index (MVI). The primary outcomes were intraoperative EBL and perioperative blood transfusion.RESULTSIn the nonembolized group, the MVI correlated with intraoperative EBL when controlling for tumor volume (r = 0.55, p = 0.002). The MVI also correlated with perioperative blood transfusion (point-biserial correlation [rpb] = 0.57, p = 0.001). A greater MVI was associated with an increased risk of blood transfusion (odds ratio [OR] 5.79, 95% confidence interval [CI] 1.15-29.15) and subtotal resection (OR 7.64, 95% CI 1.74-33.58). In the embolized group, those relationships were not found. There were no significant differences in MVI, intraoperative EBL, or blood transfusion across groups.CONCLUSIONSThis study clearly shows a relationship between MVI and intraoperative EBL in nonembolized meningiomas when controlling for tumor volume. The MVI is a potential biomarker for tumors that would benefit from embolization.

Protein-Losing Enteropathy in Patients With Congenital Heart Disease.

BACKGROUND: Protein-losing enteropathy (PLE), characterized by loss of proteins in the intestine, is a devastating complication in patients with congenital heart disease. The cause of PLE is unknown, but lymphatic involvement has been suspected. OBJECTIVES: The authors evaluated the use of lymphangiographic imaging and liver lymphatic embolization as a treatment for PLE. METHODS: This was a single-center, retrospective review of imaging and interventions used in 8 consecutive patients with liver lymphatic embolization and congenital heart disease with elevated central venous pressure complicated by PLE. RESULTS: Liver lymphangiography was performed in 8 patients (5 males, 3 females; median age, 21 years), 7 of whom demonstrated leakage of liver lymph into the duodenum through abnormal hepatoduodenal lymphatic communications. This was confirmed by duodenoscopy with simultaneous injection of isosulfan blue dye into the liver lymphatics in 6 of 7 patients. Liver lymphatic embolization with ethiodized oil in 2 patients resulted in a temporary increase in albumin blood level and symptom improvement in 1 patient, but was complicated by duodenal bleeding in both patients. Of the remaining 6 patients, liver lymphatic embolization with n-butyl cyanoacrylate glue resulted in sustained improvement of the serum albumin level and symptoms in 3 patients, temporary improvement in 2 patients, and no change in 1 patient with median follow-up of 135 days (range, 84 to 1,005 days). CONCLUSIONS: The authors demonstrated liver lymph leakage as a cause of PLE in patients with congenital heart disease and elevated central venous pressure. Lymphatic embolization led to improved albumin levels and relief of symptoms. Further experience with the technique is needed to determine long-term outcome of this procedure.

Endovascular management of spinal dural arteriovenous fistulas.

Spinal dural arteriovenous fistulas (dAVF) are the most common subset of the larger group of spinal vascular malformations. In this chapter, we discuss the definition, epidemiology, clinical presentation, diagnosis, treatment, and outcomes of spinal dAVF. Special attention is given to clinical approach, imaging, and diagnosis with discussion of newer spinal magnetic resonance angiographic techniques. Endovascular management techniques are discussed, including technical and safety considerations for the performance of spinal angiography and various methods of embolization. Embolization media, including liquid embolics, particles, and coils, are introduced. Finally, clinical and imaging outcomes are discussed with attention to the clinical and imaging findings of dAVF recurrence.

Endovascular approaches to pial arteriovenous malformations.

Endovascular approaches to arteriovenous malformations (AVMs) are often necessary to define and help treat these often complex lesions. Angiography provides important information to help plan surgical or radiosurgical approaches. Modern embolization techniques allow AVMs to be treated with the goals of making surgery safer and easier, eliminating high-risk features in patients with AVMs who are otherwise not candidates for treatment, and even potentially curing the patient of the lesion. Liquid embolic agents have significantly advanced what is possible with endovascular treatment of AVMs.

Feasibility and outcomes of endovascular embolization of cerebral arteriovenous malformations at a low-volume centre.

BACKGROUND AND PURPOSE: Herein, we report our initial experience with the endovascular management of cerebral arteriovenous malformations (AVMs) using the liquid embolic agent Onyx and n-butyl cyanoacrylate for AVM embolization. METHODS: We reviewed data from 15 patients with brain AVMs, who were observed at our endovascular facility from January 2008 to July 2011. All cases were embolized with Onyx and/or n-butyl cyanoacrylate. There were 8 women and 7 men with a mean age of 27.2 years (range 17-43 years). The clinical presentations included intracerebral haemorrhage (n = 7), seizures (n = 4), headache (n = 2), and focal neurological deficits (n = 2); according to the Spetzler-Martin classification (Spetzler R and Martin N (1986) J NeurosurgV65 446-83), 8 AVMs were grades I-II, 5 were grade III, and 2 were grades IV-V. RESULTS: A total of 31 embolization procedures were performed in 15 patients, and 44 feeding pedicles were embolized, ranging from 1 to 5 per patient, with an average size reduction of 70% (median 75%, range 40-100%). Total obliteration was achieved for 3 AVMs (20%) (2 patients had single feeders and 1 patient had double feeders), and a partial embolization was achieved in 12 patients (80%). The procedure was related to a permanent disabling morbidity in one patient (6.6%), and no mortalities occurred. CONCLUSIONS: The outcome of (AVM) embolization in our centre is comparable to the reported outcome in other larger-volume centres. The feasibility and safety of AVM embolization in our low-volume centre are similar to the outcomes reported at high-volume centre.

ONYX versus n-BCA for embolization of cranial dural arteriovenous fistulas.

PURPOSE: To evaluate the efficacy of n-butyl-2-cyanoacrylate (Trufill n-BCA) versus ethylene vinyl alcohol copolymer (ONYX) for the embolization of cranial dural arteriovenous fistulas (DAVF). METHODS: Fifty-three consecutive patients with cranial dural AVF were treated with liquid embolic agents from November, 2003 to November, 2008. These 53 patients had 56 lesions treated with arterial embolization. Patients embolized to completion underwent follow-up angiography at 3 months to assess for durable occlusion. RESULTS: Twenty-one lesions were treated with n-BCA. Seven patients treated with n-BCA had initial angiographic occlusion of their DAVF, which were durable at 3 months. Six patients had adjunctive treatment with coils and/or polyvinyl alcohol particles, but none of these were occluded by endovascular treatment alone. Eleven patients underwent post-embolization surgery for closure of their DAVF. There was one death related to intractable status epilepticus at presentation. One patient developed a major stroke from venous sinus thrombosis after embolization. Thirty-five lesions were treated with ONYX in 34 patients. Twenty-nine patients treated with ONYX had initial angiographic occlusion of their DAVF by embolization alone. One patient had recurrence at 3 months and was re-treated out of 27 total follow-ups. Four patients underwent post-embolization surgical obliteration of their lesions. No deaths or major strokes occurred in this cohort. CONCLUSION: Initial angiographic occlusion (p=0.0004) and durable angiographic occlusion (p=0.0018) rates for embolization of cranial DAVF show a statistically significant higher efficacy with ONYX compared with n-BCA. Patients embolized with ONYX underwent surgery less frequently compared with those treated with n-BCA (p=0.0015).