RESUMO
BACKGROUND & OBJECTIVE: Glomus tympanicum and jugulare tumors are highly vascular and are therefore commonly embolized before surgical resection to prevent intra-operative bleeding. We report a case of facial nerve paralysis after pre-operative embolization for a glomus tympanicum tumor with ethylene vinyl alcohol (EVOH also known as Onyx) embolic agent. We discuss the choice of embolic agent in relation to the risk of this complication and potential management strategies. METHODS: A 57F with right glomus tympanicum developed right facial nerve palsy immediately after embolization. She received 24 mg of dexamethasone over the course of 24 h immediately following her embolization, surgical facial nerve decompression concurrent with tumor resection, and a 10-day prednisone taper. Our main outcome measure was facial nerve function on follow-up physical examinations. RESULTS: The patient developed right facial paralysis (HB 6/6) after Onyx embolization of branches of the external carotid artery system, likely due to translocation of embolic agent into facial nerve vasa nervosa as seen on post-embolization CT. No immediate improvement was observed with high dose steroids and decompression, however over the next 6 months her facial nerve function began to improve (HB 3/6). CONCLUSIONS: Surgical excision is the standard of care for glomus jugulare and glomus tympanicum tumors. Due to their propensity to bleed, their arterial feeders (branches of the external carotid) are often embolized prior to surgery, however, facial nerve paralysis is a rare but serious complication. There is a possible relationship between the choice of embolic agent and this complication. Though facial palsy is of sufficient rarity that no standard treatment pathway exists, due to the impact on a patient's quality of life, we recommend aggressive therapy to salvage nerve function.
Assuntos
Embolização Terapêutica , Paralisia Facial , Polivinil , Humanos , Feminino , Embolização Terapêutica/métodos , Embolização Terapêutica/efeitos adversos , Polivinil/administração & dosagem , Polivinil/efeitos adversos , Pessoa de Meia-Idade , Paralisia Facial/etiologia , Paralisia Facial/terapia , Resultado do Tratamento , Descompressão Cirúrgica/métodos , Descompressão Cirúrgica/efeitos adversosRESUMO
BACKGROUND: Trigeminocardiac reflex (TCR) is a brainstem reflex that can lead to hemodynamic instability manifested as bradycardia, decrease/increase of mean arterial pressure (MAP) and, in the worst case scenario, asystole during surgery. The effective intraoperative management of recurrent and profound TCR has yet to be established. This randomized paired study was performed to identify the effect of a prophylactic intra-arterial injection of lidocaine to prevent TCR caused by Onyx embolization during cerebrovascular intervention surgery. METHODS: A total of 136 patients who received Onyx embolization under general anesthesia were assigned to a control group pretreated with intra-arterial saline injection or a lidocaine group pretreated with an intra-arterial injection of 20 mg lidocaine. Heart rate (HR) and MAP were closely monitored during the embolization procedures and the incidence of TCR, mainly characterized by a decrease in HR of ≥20%, and perioperative adverse events was recorded. RESULTS: During dimethyl sulfoxide (DMSO)/Onyx injection, HR was much slower in the control group than in the lidocaine group (p<0.05). TCR occurred in 12 patients (17.6%) in the control group (cardiac arrest in 3 patients) with decreased (7 cases) or increased (5 cases) MAP, whereas no TCR was observed in the lidocaine group. Notably, most TCR episodes occurred in patients with dural arteriovenous fistula and middle meningeal artery being affected. The composite adverse events were significantly higher in the control group than in the lidocaine group (p<0.05). CONCLUSION: This prospective study shows that a prophylactic intra-arterial injection of 20 mg lidocaine could be recommended as a novel strategy to effectively and safely prevent TCR during endovascular embolization.
Assuntos
Malformações Vasculares do Sistema Nervoso Central , Embolização Terapêutica , Parada Cardíaca , Reflexo Trigêmino-Cardíaco , Humanos , Malformações Vasculares do Sistema Nervoso Central/terapia , Dimetil Sulfóxido , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/métodos , Parada Cardíaca/etiologia , Injeções Intra-Arteriais , Lidocaína/farmacologia , Lidocaína/uso terapêutico , Polivinil/efeitos adversos , Estudos Prospectivos , Reflexo Trigêmino-Cardíaco/fisiologia , Resultado do TratamentoRESUMO
In the postnatal period, extensive peripheral arteriovenous malformations (AVM) are associated with high morbidity, especially when localized in the liver. Their urgent treatment is always a challenging problem in neonates and infants. We analyzed four consecutive children aged three days to three years who underwent eight liquid embolization procedures with ethylene-vinyl alcohol copolymer. The AVM were situated on the thoracic wall, in the liver, and on the lower leg. In three cases, the malformations showed total regression. The tibial AVM degenerated widely. If impaired beforehand, cardiac or hepatic function normalized after the interventions. There were no embolization-associated complications such as nontarget embolization or tissue ischemia. We conclude that application of ethylene-vinyl alcohol copolymer seems to be a safe therapeutic option and can be used in neonates and infants with peripheral AVM in consideration of the agent's characteristics. Nevertheless, there are still hardly any data concerning young children.
Assuntos
Malformações Arteriovenosas , Embolização Terapêutica , Malformações Arteriovenosas/tratamento farmacológico , Malformações Arteriovenosas/terapia , Criança , Pré-Escolar , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/métodos , Humanos , Recém-Nascido , Polivinil/efeitos adversos , Resultado do TratamentoRESUMO
PURPOSE: Endoleaks are common following endovascular aneurysm repair (EVAR), and the liquid embolic material Onyx has been widely used in their treatment. We report our experience of long-term morphological changes of Onyx casts on surveillance imaging. MATERIALS AND METHODS: We identified 10 patients over 10 years who underwent Onyx embolization in our institution. Morphological changes of Onyx casts were assessed on surveillance radiographs and computed tomography (CT) scans. Relevant outcome data and sequelae were obtained via electronic patient records. RESULTS: Twelve procedures were performed on 10 cases, 9 for type 2, and 1 for a type 1a endoleak. Five cases showed evidence of Onyx fragmentation on follow-up imaging ranging from a single fracture to gross fragmentation with migration of fragments. Of these 5, 3 had achieved primary success but 2 went on to develop recurrence of endoleak. Onyx volume ranged from 4 to 46.5 ml (median 10.5 ml) per patient with larger volumes demonstrating the most marked fragmentation on follow-up. Follow-up ranged from 9 months to 8 years (median 2.25 years). CONCLUSION: To our knowledge, this is the first report of Onyx fragmentation after endoleak embolization. If long-term morphological stability of the Onyx cast is necessary to maintain aneurysm seal, then Onyx may not offer a permanent solution to some patients with post-EVAR endoleaks. Our study cannot ascertain whether the observed changes were the cause or the effect of ongoing aneurysm growth, persistent endoleak, and/or other forces acting on the solidified polymer, but it raises important questions on the use of Onyx in this setting.
Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/métodos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Humanos , Polivinil/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: To prospectively evaluate the efficacy and safety of a new ethylene vinyl alcohol (EVOH) copolymer-based embolic agent in the treatment of symptomatic peripheral arteriovenous malformations (AVMs). MATERIALS AND METHODS: This prospective single-center study evaluated EVOH embolization with 3 different formulations of EVOH (Squid Peri 12 cP, 18 cP, and 34 cP; BALT Germany GmbH, Düsseldorf, Germany) in patients with symptomatic AVMs. Between April 2018 and October 2019, 36 embolization procedures in 21 patients (3 males and 18 females; mean age, 34.7 years) were performed (inclusion criteria: symptomatic peripheral AVM, ≥14 years of age, and elective embolization). Symptoms, technical aspects (transarterial, transvenous, or percutaneous approach; plug or balloon occlusion), clinical and technical success (defined as the improvement of symptoms and complete angiographic eradication of the AVM nidus), adverse events, and short-term outcomes were assessed. RESULTS: The mean volume of the embolic agent used per session was 3.4 mL of EVOH 34 cP (standard deviation [SD], ± 5.4), 6.2 mL ± 8.1 of EVOH 18 cP, and 4.6 mL ± 10.1 of EVOH 12 cP. Angiographic success was achieved in 18 patients (85.7%). The mean follow-up was 190 days (range, 90-538 days; median, 182 days). In the follow-up assessment, findings of magnetic resonance imaging showed that 19 patients (90.5%) had a persistent state of devascularization compared with postinterventional angiography. Amelioration or complete elimination of pain was achieved in 90.0% of the patients. One patient experienced a major adverse event; minor adverse events developed in 2 patients. CONCLUSIONS: In this study, EVOH appeared to be a safe and effective embolic agent in peripheral AVMs and had a low rate of adverse events in a limited number of patients.
Assuntos
Malformações Arteriovenosas , Embolização Terapêutica , Malformações Arteriovenosas Intracranianas , Adulto , Malformações Arteriovenosas/diagnóstico por imagem , Malformações Arteriovenosas/terapia , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/métodos , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/tratamento farmacológico , Malformações Arteriovenosas Intracranianas/etiologia , Masculino , Polivinil/efeitos adversos , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Curetagem/efeitos adversos , Dimetil Sulfóxido/efeitos adversos , Eletrocoagulação/efeitos adversos , Embolização Terapêutica/efeitos adversos , Complicações Intraoperatórias/etiologia , Polivinil/efeitos adversos , Idoso de 80 Anos ou mais , Animais , Fístula Arteriovenosa/terapia , Biópsia , Carcinoma in Situ/patologia , Carcinoma in Situ/cirurgia , Curetagem/métodos , Dimetil Sulfóxido/administração & dosagem , Eletrocoagulação/métodos , Embolização Terapêutica/métodos , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Ceratose Actínica/patologia , Ceratose Actínica/cirurgia , Masculino , Polivinil/administração & dosagem , Couro Cabeludo/patologia , Couro Cabeludo/cirurgia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Carcinoma de Células Escamosas de Cabeça e Pescoço/patologia , Carcinoma de Células Escamosas de Cabeça e Pescoço/cirurgiaRESUMO
BACKGROUND: Copolymer (Onyx) embolization is an effective treatment for dural arteriovenous fistula (dAVF), however, some dAVFs have multiple, high-flow feeding vessels, resulting in insufficient embolization. For the treatment of such patients, we have developed a novel flow-control technique, the 'damp-and-push technique'. The purpose of this study was to evaluate the technical efficiency and safety of this technique. METHODS: Seven patients who had been diagnosed with intracranial dAVF were treated by transarterial Onyx embolization using the damp-and-push technique between 2016 and 2019. This technique was designed to reduce blood flow to the shunt site using a balloon catheter in the major feeding vessel other than the one injected with Onyx, leading to better Onyx penetration and enabling more controlled embolization of complex dAVFs. Retrospectively collected data were reviewed to assess the occlusion rates and clinical outcomes. RESULTS: The dAVF was at a transverse sinus-sigmoid sinus junction in four patients, in the superior sagittal sinus in two, and in the tentorium in one. Five cases were Cognard type â ¡b and two cases were Cognard type â £. All the patients were treated by transarterial Onyx injection via the main feeding vessel, combined with flow reduction in the other main feeding vessel using a balloon catheter. Complete occlusion was achieved in six patients and elimination of cerebral venous reflux was achieved in all the patients. There were no immediate or delayed post-interventional complications. CONCLUSIONS: Transarterial Onyx embolization of dAVF using the damp-and-push technique is safe and yields a high complete occlusion rate.
Assuntos
Malformações Vasculares do Sistema Nervoso Central/terapia , Dimetil Sulfóxido/uso terapêutico , Embolização Terapêutica , Polivinil/uso terapêutico , Adulto , Idoso , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Malformações Vasculares do Sistema Nervoso Central/fisiopatologia , Circulação Cerebrovascular , Dimetil Sulfóxido/efeitos adversos , Embolização Terapêutica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polivinil/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Embolização Terapêutica/efeitos adversos , Hemorragia Gastrointestinal/terapia , Jejuno/irrigação sanguínea , Polivinil/efeitos adversos , Evolução Fatal , Hemorragia Gastrointestinal/diagnóstico por imagem , Humanos , Jejuno/patologia , Masculino , Pessoa de Meia-Idade , Necrose , Polivinil/administração & dosagem , Recidiva , Retratamento , Resultado do TratamentoAssuntos
Falso Aneurisma/terapia , Aneurisma Roto/terapia , Embolização Terapêutica/efeitos adversos , Migração de Corpo Estranho/etiologia , Claudicação Intermitente/etiologia , Região Lombossacral/irrigação sanguínea , Doença Arterial Periférica/etiologia , Polivinil/efeitos adversos , Tantálio/efeitos adversos , Adulto , Falso Aneurisma/diagnóstico por imagem , Aneurisma Roto/diagnóstico por imagem , Combinação de Medicamentos , Feminino , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/cirurgia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/cirurgia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Resultado do TratamentoRESUMO
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.
Assuntos
Embolização Terapêutica , Malformações Arteriovenosas Intracranianas , Adulto , Encéfalo , Dimetil Sulfóxido/efeitos adversos , Embolização Terapêutica/efeitos adversos , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Polivinil/efeitos adversos , Estudos Prospectivos , Resultado do TratamentoRESUMO
Endovascular procedures with liquid embolic agents such as ethylene-vinyl alcohol (EVOH) copolymers are indicated before surgical treatment of cervical paraganglioma. Consequently, these agents are now available as low viscosity formulations, one of which is Squid 12, which are demonstrating superior vascular penetration. Cases of facial paralysis secondary to embolization of cervical vascular lesions with classic embolic agents have been reported in the English literature, however, this complication has not been described with new generation options such as Squid 12.We describe the case of a 43-year-old patient with a left neck carotid paraganglioma. Embolization was performed under general anaesthesia before surgical excision. In the immediate postoperative period, the patient developed total left facial palsy. Since the imaging tests (Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)) and neurological examination showed no involvement of additional cranial nerves (CN), we hypothesise that the main cause of this complication is ischemia of the vasa nervorum of CN VII secondary to embolization. Almost six months later, the patient continues to present total facial paralysis (Grade VI House-Brackmann facial paralysis scale), and palsy of the left CN X and XII as a complication secondary to surgical resection of the paraganglioma.This case is relevant since it is the first clinical case of permanent facial paralysis secondary to embolization with Squid 12.
Assuntos
Embolização Terapêutica/efeitos adversos , Paralisia Facial/etiologia , Neoplasias de Cabeça e Pescoço/terapia , Paraganglioma/terapia , Polivinil/efeitos adversos , Adulto , Embolia/induzido quimicamente , Embolização Terapêutica/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Imageamento por Ressonância MagnéticaRESUMO
OBJECTIVE: Little evidence is available supporting the optimal treatment of type II endoleaks associated with aortic sac growth. Previous studies have lacked comparisons between treatment methods and long-term follow-up. The purpose of the present study was to review our center's experience with the treatment of type II endoleaks comparing Onyx (a liquid embolization agent consisting of ethylene vinyl alcohol; Medtronic, Minneapolis, Minn) embolization and coil embolization. METHODS: A retrospective review of prospectively collected data from a vascular surgery database was performed to identify all patients who had undergone embolization of a type II endoleak for aortic sac growth after endovascular aneurysm repair from 2005 to 2018. The Onyx and coil embolization groups were compared using univariate statistics. RESULTS: A total of 58 patients had undergone 77 embolization procedures for type II endoleaks with either Onyx (27 patients; 37 procedures) or coils (31 patients; 40 procedures). The average aneurysm size at embolization was larger in the Onyx group (77.9 ± 15.1 mm) compared with coil embolization (73.4 ± 11.9 mm). The mean follow-up was 57 months for the Onyx group and 74 months for the coil embolization group. Of the 27 patients who had undergone Onyx embolization, 2 (7.4%) had required graft explantation compared with 5 of the 31 patients (16.1%) who had undergone coil embolization (P = .33). The results of the per-patient analysis showed that the coil embolization group had a significantly greater rate of the need for further reintervention compared with the Onyx group (55% vs 19%; P < .01). Clinical success was observed in 13 patients (48%) in the Onyx embolization group compared with 10 patients (32%) in the coil embolization group (P = .04). Two patients in each group had presented with secondary rupture of the aneurysm sac after attempted embolization. CONCLUSIONS: Type II endoleaks associated with sac growth treated with Onyx were less likely to require further reinterventions than were those treated with coil embolization. A trend was found toward a greater need for endovascular aneurysm repair explant after coil embolization. With a high rate of further reintervention and potential for sac rupture, diligent follow-up is required after attempted type II embolization, regardless of the technique used.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Dimetil Sulfóxido/administração & dosagem , Embolização Terapêutica/instrumentação , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Polivinil/administração & dosagem , Bases de Dados Factuais , Dimetil Sulfóxido/efeitos adversos , Embolização Terapêutica/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Feminino , Humanos , Masculino , Polivinil/efeitos adversos , Retratamento , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: This study reports our experience with the use of an ethylene vinyl alcohol copolymer (Onyx™) for the treatment of type II endoleak after endovascular repair of abdominal aortic aneurysms (EVAR) in comparison to coils and cyanoacrylate glue. METHODS: Clinical data of all patients treated for type II endoleak following EVAR between 2009 and 2017 were retrospectively analyzed. Abdominal aortic aneurysm (AAA) diameter and AAA sac volume during follow-up were measured using computed tomography angiography (CTA). Treatment failure variables were created for the change in sac diameter and volume. An increase in sac diameter ≥ 5 mm was considered a failure, as was an increase ≥ 10% in AAA sac volume. RESULTS: 35 patients underwent treatment for a persistent type II endoleak following EVAR. Of these patients, 18 (51.4%) were treated with Onyx and 17 (48.6%) were treated with coils ± cyanoacrylate glue embolization. There were no significant differences between the 2 groups with regard to demographics. The average volume of Onyx used per treatment was 13.4 ml (range 4.5 ml- 39 ml). There was no difference in efficacy between the Onyx and non-Onyx group. Complications were limited to 1 non-target embolization without significant clinical sequelae. CONCLUSIONS: Ethylene vinyl alcohol copolymer (Onyx™) embolization is similarly effective compared to traditional cyanoacrylate glue or coil embolization in the treatment of type II endoleak after EVAR.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Cianoacrilatos/administração & dosagem , Embolização Terapêutica , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Polivinil/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Cianoacrilatos/efeitos adversos , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/instrumentação , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Feminino , Humanos , Masculino , Polivinil/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Aneurisma da Aorta Abdominal/cirurgia , Dimetil Sulfóxido/administração & dosagem , Embolização Terapêutica , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Polivinil/administração & dosagem , Veias Renais , Idoso , Dimetil Sulfóxido/efeitos adversos , Embolização Terapêutica/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Humanos , Masculino , Polivinil/efeitos adversos , Veias Renais/diagnóstico por imagem , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Hemorrhagic complication is a disastrous complication of intracranial dural arteriovenous fistulas (DAVFs) embolization. This study was to analyze the possible risk factors for the hemorrhagic complication caused by endovascular embolization of DAVFs. METHODS: From January 2012 to July 2016, a total of 267 patients with intracranial DAVFs received endovascular Onyx embolization at our hospital. The demographic information, clinical presentation, angiographic features, endovascular treatment and hemorrhagic complications were reviewed. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors contributing to the post-procedural hemorrhagic complications. RESULTS: In 267 patients of DAVF treated with endovascular embolization, procedure-related hemorrhagic complication occurred in 12 (4.5%) patients. Univariate and multivariate logistic regression analyses showed that the pial arterial supplier (OR 13.630; 95% CI, 1.556-119.368; P = 0.018), giant venous aneurysm (OR 15.196; 95% CI, 2.505-92.183; P = 0.003) and Onyx volume ≥ 6 ml (OR 1.138; 95% CI, 1.006-1.288; P = 0.040) were significant factors associated with these hemorrhagic complications. CONCLUSIONS: Hemorrhagic complications associated with endovascular DAVF embolization are not negligible. The pial arterial supplier, giant venous aneurysm and higher Onyx volume in one session may be risk factors for endovascular DAVF embolization.
Assuntos
Malformações Vasculares do Sistema Nervoso Central/terapia , Hemorragia Cerebral/etiologia , Dimetil Sulfóxido/efeitos adversos , Embolização Terapêutica/efeitos adversos , Polivinil/efeitos adversos , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Angiografia Cerebral , Hemorragia Cerebral/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Foramen magnum dural arteriovenous fistula (DAVF) is a rare disease, with some reported cases of successful treatment. We achieved complete obliteration of the foramen magnum DAVF through microsurgery after complications of endovascular embolization. We reviewed the treatment modalities and outcomes, focusing on pathologic and anatomic features from the literature. CASE DESCRIPTION: A 65-year-old man was admitted to our hospital with sudden diplopia. Magnetic resonance imaging revealed a subarachnoid hemorrhage around the right side of the prepontine cistern, and a foramen magnum DAVF was diagnosed by angiography. Subsequent angiography revealed that the fistula was supplied by the right neuromeningeal trunk of the ascending pharyngeal artery and the right posterior meningeal artery of the vertebral artery (VA), and the veins of the pouch via the fistula were retrogradely draining into the intracranial veins. We aimed to treat complete occlusion endovascularly with balloon-augmented transarterial Onyx injection via the posterior meningeal artery, but Onyx was refluxed to the VA through the anastomosis between the VA and posterior meningeal artery. Onyx subsequently migrated to the top of the basilar artery, causing occlusion, so we urgently removed the Onyx with a stent retriever (Trevo). Several weeks later, we performed complete obliteration of the foramen magnum DAVF via a lateral suboccipital approach with a C1 laminectomy. CONCLUSIONS: Most foramen magnum DAVFs were obliterated completely with only endovascular treatment. Microsurgery is an effective and reliable treatment for incomplete occlusion and complications.
Assuntos
Malformações Vasculares do Sistema Nervoso Central/cirurgia , Dimetil Sulfóxido/efeitos adversos , Forame Magno/cirurgia , Microcirurgia/métodos , Polivinil/efeitos adversos , Falha de Tratamento , Idoso , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Dimetil Sulfóxido/administração & dosagem , Forame Magno/diagnóstico por imagem , Humanos , Masculino , Polivinil/administração & dosagemRESUMO
"Skin popping" refers to the practice of injecting drugs, most commonly heroin, subcutaneously or into granulation tissue. Pharmaceutical tablets meant for oral consumption are modified into solutions for injection. Excipients-inactive substances that serve as vehicles for medication-are often not filtered out before injection and result in abscess formation, granulomatous inflammation, and scarring. Common excipients used in the production of pharmaceutical tablets include starch, microcrystalline cellulose, magnesium stearate, silica, and polyvinylpyrrolidone (PVP). Identification of these exogenous materials is valuable in confirming the diagnosis of skin popping, especially when patients may not be forthcoming about their drug use. We present a case of subcutaneous oral medication injection in which PVP and cellulose were identified by Fourier transform infrared spectroscopy. Considering the variable cutaneous manifestations of injection drug abuse, recognition of histopathologic and chemical characteristics of exogenous material from oral medications is helpful for diagnosis and intervention.
Assuntos
Excipientes/análise , Reação a Corpo Estranho/diagnóstico , Injeções Intradérmicas , Espectroscopia de Infravermelho com Transformada de Fourier/métodos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adulto , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Celulose/efeitos adversos , Celulose/análise , Excipientes/efeitos adversos , Feminino , Reação a Corpo Estranho/induzido quimicamente , Humanos , Oxicodona/administração & dosagem , Oxicodona/efeitos adversos , Polivinil/efeitos adversos , Polivinil/análise , Pirrolidinas/efeitos adversos , Pirrolidinas/análise , Dermatopatias/induzido quimicamente , Dermatopatias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/patologiaRESUMO
PURPOSE: To assess the feasibility, safety, and efficacy of balloon-assisted delivery of ethylene vinyl alcohol copolymer (EVOH) for a range of peripheral arterial applications. MATERIALS AND METHODS: Six academic medical centers entered retrospective data on 46 consecutive patients (27 men, 19 women; ages, 11-94 y; mean age, 50.3 y) who underwent 60 balloon-assisted EVOH procedures. The cohort was restricted to procedures involving peripheral, nonneural arteries 1-5.5 mm in diameter. Clinical indications included a wide range of vascular pathologic conditions (most commonly arteriovenous malformations [n = 20], renal angiomyolipomas [n = 8], and acute hemorrhage [n = 9]) and targeted visceral and musculoskeletal peripheral arteries. Data collected included sex, age, clinical indication, arterial pathology, arteries embolized, type of occlusion balloon microcatheter, type and concentration of EVOH agent, effectiveness as an embolic backstop, vessels protected, adequacy of EVOH cast penetration, catheter extraction, nontarget embolization, and complications. RESULTS: Balloon occlusion prevented EVOH reflux in 59 of 60 procedures (98.3%). Nontarget EVOH embolization occurred in 2 procedures (3.3%). Adequate EVOH cast penetration and complete filling of the target pathologic structure were seen in 57 of 60 procedures (95%). Balloon deflation and uneventful extraction occurred in all procedures; small EVOH fragments detached into target arteries in 2 cases. One major (1.7%) and 2 minor (3.3%) complications occurred. CONCLUSIONS: Balloon-assisted EVOH embolization of peripheral arteries is feasible, safe, effective, and versatile. The primary advantage of balloon-assisted EVOH embolization is the ability to apply more injection pressure to advance the EVOH cast assertively into the pathologic structure(s).
Assuntos
Malformações Arteriovenosas/terapia , Oclusão com Balão , Neoplasias/terapia , Polivinil/administração & dosagem , Doenças Vasculares/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Malformações Arteriovenosas/diagnóstico por imagem , Oclusão com Balão/efeitos adversos , Criança , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico por imagem , Neoplasias/patologia , Polivinil/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Doenças Vasculares/diagnóstico por imagem , Adulto JovemRESUMO
PURPOSE: To report the safety and efficacy of the embolization of splenic artery aneurysms (SAAs) with coils plus ethylene vinyl alcohol copolymer (EVOH) agent. MATERIALS AND METHODS: A single-center retrospective study was conducted from 2016 to 2019 to collect SAAs. Twelve asymptomatic patients (mean age, 59 years) with 15 SAAs (mean size, 23.6 mm; size range, 15-40 mm) were treated with embolization. Embolization was performed with EVOH (Squid 8/34) and fibered detachable coils. Transfemoral embolization was performed with a microcatheter to achieve a splenic artery occlusion embolizing the SAA and its efferent and afferent branches. Follow-up was based on color Doppler ultrasound at 24 hours and on computed tomography (CT) angiography at 1 (n = 12) and 6 months (n = 12) after embolization. Mean number of coils and Squid vials used for each patient, major/minor complications, technical success, 30-day clinical success, cases of revascularization/reintervention, and mortality were assessed. Technical success was defined as complete exclusion of the aneurysmal segment and cessation of blood flow into the sac. Clinical success at 1 month was based on the absence of clinical symptoms and the exclusion of aneurysm revascularization on CT angiography. RESULTS: The mean number of coils and Squid vials was 5.75 (standard deviation [SD], 1.58; range, 3-9) and 1.41 (SD, 0.49; range, 1-2), respectively. Both technical and 30-day clinical success were 100%, with no cases of aneurysm revascularization (CT angiography performed in all patients at 1 month and 6 months and in 3 patients at 24 months). No major complications or fatal events were recorded. In terms of minor complications, 2 cases of mild pancreatitis (transient amylases increase) and 1 case of focal splenic ischemia without clinical sequelae were recorded. CONCLUSIONS: Embolization in SAAs using coils plus EVOH was safe and effective without SAA revascularization.
Assuntos
Aneurisma/terapia , Polivinil/administração & dosagem , Artéria Esplênica , Idoso , Idoso de 80 Anos ou mais , Aneurisma/diagnóstico por imagem , Embolização Terapêutica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polivinil/efeitos adversos , Estudos Retrospectivos , Artéria Esplênica/diagnóstico por imagem , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Type II endoleaks (T2ELs) are common following endovascular repair of abdominal aortic aneurysms (EVAR). Embolization with ethylene vinyl alcohol copolymer (Onyx) may present an effective treatment alternative for T2ELs. Due to limited data supporting its use, we sought to analyze outcomes of Onyx embolization for T2ELs. METHODS: Retrospective review of consecutive patients treated for T2ELs utilizing Onyx embolization agent from 2009-2018. All pre- and post-Onyx intervention CT scans were analyzed for diameter and volume changes with 3D reconstruction software. The primary outcomes were change in maximum AAA diameter and volume. Secondary outcomes included additional interventions, rupture, and mortality. A subset analysis was performed with patients with isolated T2ELs (no other types of endoleaks present). RESULTS: We identified 85 patients (73 males, mean age 77.6 ± 7.6 years) who underwent 112 Onyx interventions. Average time to first Onyx intervention after index EVAR was 3.3 ± 2.6 years and average sac growth was 6.3 ± 6.7 mm. Patients underwent mean 1.3 Onyx interventions using a mean of 4.9 ± 4.7 ml for treatment. Three complications occurred (Onyx extravasation, colon ischemia, and access site hematoma). Mean follow-up was 2.5 ± 2.1 years after initial Onyx treatment. At the most recent follow-up, sac diameter stabilization was seen in 47% and reduction >5 mm was seen in 19%. Sac growth of >5 mm was seen in 34% of patients following the first Onyx intervention. In our subset of isolated T2EL, 72% had sac stabilization or reduction >5 mm. Four patients experienced a ruptured aneurysm (3 had active type 1 endoleaks). Rupture-free survival was 95% at 5 years, and overall survival was 54% at 5 years. Notably, increasing Onyx interventions were not associated with sac stabilization or reduction (OR 0.6, P = 0.1). On multivariable analysis, AAA sac diameter stabilization or reduction was independently associated with BMI >30 kg/m2 (OR 4.2, P = 0.01) and having only 1 Onyx intervention (OR 3.8, P = 0.02). CONCLUSIONS: Onyx for embolization of T2ELs resulted in AAA sac diameter stabilization or reduction in 66% of patients, and up to 72% in isolated T2ELs. Further, increasing Onyx interventions were not associated with either aneurysm sac stabilization or reduction. Given its similar outcomes to other embolization strategies in the literature, Onyx embolization for management of T2ELs needs to be judiciously considered, particularly for T2ELs persisting after an initial Onyx embolization intervention.