Balloon-Assisted Embolization of Wide-Neck Aneurysms Using a Mixture of n-Butyl Cyanoacrylate, Lipiodol, and Ethanol in Swine: A Comparison of Four n-Butyl Cyanoacrylate Concentrations.

PURPOSE: To determine the optimal ratio of n-butyl cyanoacrylate (NBCA)-Lipiodol-ethanol (NLE) mixture for balloon-assisted embolization of wide-neck aneurysms. MATERIALS AND METHODS: We created 32 wide-neck aneurysms on both the common carotid arteries and external iliac arteries in eight female swine. Eight aneurysms were randomly assigned to four groups. Under balloon occlusion, the aneurysms were packed using NLE at one of four ratios of NLE: 2:2:1 (NLE221; 40%NBCA); 3:6:1 (NLE361; 30%NBCA); 2:7:1 (NLE271; 20%NBCA); and 1:5:1 (NLE151; 14.3%NBCA). We performed angiography before and after embolization to assess the aneurysms, and we compared adhesion between NLE and the balloon and assessed NLE migration. Three days after embolization, the aneurysms were removed for histopathologic evaluation. RESULTS: Embolization was performed in 27 aneurysms. Adhesion between NLE and the balloon was not observed in any group. NLE migration was found in 0/7 aneurysms in the NLE221 group, 0/6 in the NLE361 group, 5/6 in the NLE271 group, and 7/8 in the NLE151 group. NLE migration was significantly lower in the NLE221 group than in the NLE271 and NLE151 groups (P = 0.0047 and 0.0014, respectively) and was significantly lower in the NLE361 group than in the NLE271 and NLE151 groups (P = 0.0152 and 0.0047, respectively). Media necrosis of the arterial wall close to the aneurysms was observed in all groups. CONCLUSION: NLE with an NBCA concentration of ≥ 30% is a safe and feasible embolic material for balloon-assisted embolization of wide-neck aneurysms in swine in the short term up to 3 days after embolization.

Prophylactic Intraoperative Embolization of Abdominal Aortic Aneurysm Sacs Using N-Butyl Cyanoacrylate/Lipiodol/Ethanol Mixture with Proximal Neck Aortic Balloon Occlusion during Endovascular Abdominal Aortic Repair.

PURPOSE: To determine the feasibility of prophylactic intraoperative abdominal aortic aneurysm (AAA) sac embolization using a mixture of N-butyl cyanoacrylate/Lipiodol/ethanol (NLE) with proximal neck aortic balloon occlusion during endovascular aneurysm repair (EVAR) to prevent the occurrence of endoleak and aneurysm sac expansion. MATERIALS AND METHODS: Prophylactic intraoperative AAA sac embolization was performed in 24 patients with an infrarenal neck angulation > 60° (n = 16) or AAA sac diameter > 60 mm (n = 17). AAA sac pressure was continuously measured with a 3-F catheter inserted into the AAA sac. The systolic sac pressure index (SPI) was calculated as the ratio of systolic AAA sac pressure to the simultaneously measured systolic aortic pressure, and was measured with and without proximal neck aortic balloon occlusion. The aneurysm sac was embolized with NLE during proximal neck aortic balloon occlusion immediately after EVAR. Endoleak and AAA sac diameter were evaluated by enhanced computed tomography and subtraction magnetic resonance imaging at 6 months and yearly after EVAR. RESULTS: Mean SPIs after EVAR with and without proximal neck aortic balloon occlusion were 0.36 and 0.57, respectively. There were no adverse events related to intraoperative sac embolization. Follow-up imaging (mean, 12.1 mo) revealed three minor endoleaks (12.5%) and no aneurysm sac expansion. CONCLUSIONS: Prophylactic intraoperative sac embolization with NLE during proximal neck aortic balloon occlusion was safe and feasible and may reduce endoleaks and prevent sac expansion after EVAR in patients with unfavorable anatomic factors.

Balloon-assisted packing of wide-neck aneurysms with a mixture of n-butyl cyanoacrylate, Lipiodol, and ethanol: an experimental study.

PURPOSE: To evaluate the feasibility of balloon-assisted packing with a mixture of n-butyl cyanoacrylate (NBCA), Lipiodol, and ethanol for wide-neck aneurysms. MATERIALS AND METHODS: Of 10 carotid aneurysms with wide necks created in a swine model, 3 aneurysms (long and short diameters 10.9 × 9.8 mm; neck width 8.3 ± 1.2 mm (mean ± SD)) and 7 aneurysms (11.2 × 9.5 mm; neck width 8.3 ± 1.4 mm) were packed with a mixture of NBCA, Lipiodol, and ethanol in the ratios 1:1:0 (NL11) and 1:1:2 (NLE112), respectively. A microcatheter was advanced into the aneurysm and a balloon catheter was inflated at the aneurysm neck. Ten minutes after injection, the balloon catheter was deflated and its removal was attempted. RESULTS: For all three aneurysms in the NL11 group, the balloon catheter and the microcatheter adhered strongly to the vessel and could not be adjusted. For all seven aneurysms in the NLE112 group, both the balloon catheter and the microcatheter could be easily removed, which enabled successful full packing of the aneurysm by re-advancing the microcatheter and re-injecting NLE112 after re-inflation of the balloon catheter. CONCLUSION: Although at a preliminary stage, balloon-assisted NLE injection is feasible for packing a wide-neck aneurysm.

Effect of transcatheter arterial embolization with a mixture of n-butyl cyanoacrylate, lipiodol, and ethanol on the vascular wall: macroscopic and microscopic studies.

PURPOSE: To compare the pathologic effect of a mixture of n-butyl cyanoacrylate (NBCA), lipiodol, and ethanol (NLE) with a mixture of NBCA and lipiodol (NL) on the embolized vascular wall. MATERIALS AND METHODS: Embolization was performed using four swine with NBCA and lipiodol in a volume ratio of 1:1 (NL11 group) in the common hepatic artery (n = 1) and the internal iliac artery (n = 2); and with NBCA, lipiodol, and ethanol in a volume ratio of 1:1:2 (NLE112 group) in the common hepatic artery (n = 3) and the internal iliac artery (n = 6). RESULTS: NL11 casts had an intricate appearance in reticular configuration with red thrombus, while NLE112 casts presented in a single round configuration with surrounding ring-like red thrombus. Desquamation of endothelial cells and infiltration of neutrophils into the adventitial layer were found in all embolized vessels in both groups. Infiltration of neutrophils into the intermediate layer was found in the NL11 group but not in the NLE112 group. CONCLUSION: The damage to the vascular wall caused by NLE112 was milder than that by NL11, implying the adverse effects of NLE112 are within tolerable limits.

Clinical evaluation of transcatheter arterial chemoembolization with 2-day-soluble gelatin sponge particles for hepatocellular carcinoma-comparison with insoluble gelatin sponge particles.

PURPOSE: To compare therapeutic effect, adverse events, and embolized hepatic artery impairment in transcatheter arterial chemoembolization between Lipiodol plus insoluble gelatin sponge particles (Gelpart) and Lipiodol plus 2-day-soluble gelatin sponge particles (2DS-GSPs). MATERIALS AND METHODS: In a single-center, prospective, randomized controlled trial, patients with hepatocellular carcinoma were assigned to the 2DS-GSP group or the Gelpart group. Radiographic response at 3 months per modified Response Evaluation Criteria In Solid Tumors was evaluated as the primary endpoint; secondary endpoints were safety (per Common Terminology Criteria for Adverse Events, version 4.0) within 3 months and hepatic branch artery impairment at the time of repeat chemoembolization (grade 0, no damage; grade I, mild vessel wall irregularity; grade II, overt stenosis; grade III, occlusion of more peripheral branch artery than subsegmental artery; grade IV, occlusion of subsegmental artery). Grade II, III, or IV indicated significant hepatic artery impairment. RESULTS: Thirty-seven patients with 143 nodules were randomized to the 2DS-GSP group and 36 patients with 137 nodules were randomized to the Gelpart group. No significant differences in patient background existed between groups. Target lesion response and overall tumor response in the 2DS-GSP and Gelpart groups were 77.7% versus 76.9% and 78.3% versus 77.8%, respectively, with no significant differences. No significant difference in adverse events existed between groups. Hepatic artery impairment was observed in 5% of patients in the 2DS-GSP group (n = 32) and in 16% in the Gelpart group (n = 33; P< .001). CONCLUSIONS: Transcatheter arterial chemoembolization with 2DS-GSPs resulted in the same therapeutic and adverse effects as chemoembolization with Gelpart while causing significantly less hepatic artery impairment.

Basic study of a mixture of N-butyl cyanoacrylate, ethanol, and lipiodol as a new embolic material.

PURPOSE: To clarify the configuration change of N-butyl cyanoacrylate (NBCA) polymerization with increasing proportion of ethanol, the properties of a mixture of NBCA with lipiodol plus ethanol (NLE), and the feasibility of use of NLE for aneurysm packing in a swine model. MATERIALS AND METHODS: The polymerization configuration of NLE was explored using ratios of 1-4 parts NBCA and 1-3 parts ethanol per 1 part of lipiodol; a 1:1 ratio of NBCA to lipiodol (NLE110) was used as a control. The distance that NLE migrated into saline flowing in a tube was measured. A carotid artery aneurysm was created in each of 18 swine. Aneurysmal packing with three configurations--NLE110, NLE at a ratio of 1:1:2 (NLE112), and NLE at a ratio of 1:1:3 (NLE113)--was attempted in six swine for each configuration. RESULTS: Regardless of NBCA composition, medium-sized droplets, a single large droplet, and a noodle-shaped extrusion were observed in NLE with lipiodol versus ethanol ratios of 1:1, 1:2, and 1:3. NLE110 migrated as viscous fluid to 190 cm from the injection site, whereas NLE112 migrated for 81 cm ± 11 and NLE113 migrated for 74 cm ± 9. Instant outflow of NLE110 from the six aneurysms caused occlusion of the parent artery, with adhesion to the microcatheter. Packing was achieved with minimal adhesion for all six of the aneurysms packed with NLE112 or with NLE113. CONCLUSIONS: With high ratios of ethanol, the NLE polymerization configuration acquired solid-like properties with potent occlusive ability and negligible adhesion to the microcatheter, suggesting its feasibility for packing of aneurysms.

Pathologic evaluation of damage to bronchial artery, bronchial wall, and pulmonary parenchyma after bronchial artery embolization with N-butyl cyanoacrylate for massive hemoptysis.

Histologic evidence of safety after bronchial arterial embolization (BAE) with N-butyl cyanoacrylate (NBCA) should be assured. The present report describes a 78-year-old man with massive hemoptysis from lung cancer who underwent surgical lobectomy 23 days after hemostasis had been achieved via BAE with NBCA. Pathologic examination revealed that NBCA filled the lumen of bronchial branch arteries 143-1,094 µm in diameter from the lobar bronchus to subsegmental bronchus but was not seen in the lumen of the pulmonary artery or pulmonary vein. NBCA induced occlusion of bronchial branch arteries but no necrosis of the bronchial wall or pulmonary parenchyma.

Prospective comparison of transcatheter arterial chemoembolization with Lipiodol-epirubicin and Lipiodol-cisplatin for treatment of recurrent hepatocellular carcinoma.

PURPOSE: The aim of this study was to compare the safety and short-term efficacy of transcatheter arterial chemoembolization (TACE) using cisplatin-Lipiodol suspension (CP/Lp) with that using epirubicin-Lipiodol emulsion (EP/Lp) in patients with recurrent hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 28 HCC patients were enrolled prospectively and assigned to the CP/Lp group or EP/Lp group. Adverse effects related to TACE were graded; and the treatment effect (TE) on HCC nodules at 3 months and overall tumor response at 6 months were assessed as the endpoint. RESULTS: No significant difference was observed between the groups regarding the frequency of adverse effects of grade 3 or less. The TE rates for 100% necrosis plus >50% necrosis in 62 HCC nodules in the CP/Lp group and 75 HCC nodules in the EP/Lp group were 72.6% and 66.7%, respectively (P = 0.894). Overall tumor response revealed that six patients (50.0%) in the CP/Lp group and six patients (37.5%) in the EP/Lp group had a partial response plus a complete response, with no significant difference (P = 0.615). TACE-free control curves for both groups revealed no significant difference (P = 0.513). CONCLUSION: No significant difference was found with regard to adverse effects, the treatment effect on HCC nodules, or overall tumor response between the CP/Lp and EP/Lp groups.

Triple-phase computed tomography during arterial portography with bolus tracking for hepatic tumors.

PURPOSE: The purpose of this study was to assess the usefulness of triple-phase computed tomography during arterial portography (CTAP) using a bolus-tracking technique. MATERIAL AND METHODS: The subjects were 60 patients with hepatic tumors: 20 patients with metastatic liver tumors with a normal liver and 40 with hypervascular hepatocellular carcinoma (HCC) with liver cirrhosis. The region of interest was set in the portal vein, and CTAP was automatically started after the triggering threshold (180 HU) was reached. Three scans were performed: early phase (E), hepatic parenchymal phase (HP), and late phase (L). The scan start time of E-CTAP was measured. The detection rates of the HCC nodules were evaluated during each CTAP phase. RESULTS: CTAP was performed by bolus tracking without failure in any of the patients. The mean scan start times in the normal liver group and liver cirrhosis group were 14.3 +/- 1.34 s and 18.5 +/- 2.46 s, respectively, which were significantly different from each other. The detection rates of HCC nodules for E-CTAP, HP-CTAP, and L-CTAP were 29.6%, 100%, and 83.3%, respectively. CONCLUSION: The bolus-tracking technique enabled us to perform CTAP with optimal timing regardless of the portal blood flow dynamics.

Effects of hepatic artery chemoembolization using cisplatin-lipiodol suspension with gelatin sponge particles on swine liver.

PURPOSE: To define the effects of hepatic artery chemoembolization with cisplatin-lipiodol suspension and gelatin sponge particles on swine liver tissue and estimate the concentration of cisplatin that would have a minimal negative effect on normal liver parenchyma. MATERIALS AND METHODS: Twelve pigs were divided into four groups: group A was the control group in which hepatic arteries were embolized with lipiodol and gelatin sponge particle (n = 3); group B animals were embolized with 10 mg/mL cisplatin-lipiodol suspension plus gelatin sponge particle (n = 3), group C with 20 mg/mL cisplatin-lipiodol suspension plus gelatin sponge particle (n = 3), and group D with 30 mg/mL cisplatin-lipiodol suspension plus gelatin sponge particle (n = 3). Pigs were euthanized 1 week after embolization, and the resected livers were cut into 10-mm-thick sections. The livers and necrotic foci were contoured in each section, and the necrosis volume ratio was calculated. RESULTS: The necrosis volume ratios of the livers in groups A, B, C, and D were 0.832% +/- 0.334, 2.324% +/- 1.126, 8.056% +/- 3.276, and 11.82% +/- 4.921, respectively. Significant differences (P < .05) in necrosis volume ratio were found between groups A and C, groups A and D, groups B and C, and groups B and D; no significant difference was found between groups A and B. CONCLUSIONS: Hepatic artery chemoembolization with higher doses of cisplatin causes greater damage to liver tissue; 10 mg/mL cisplatin-lipiodol suspension causes minimal damage, similar to that without cisplatin, and is related to minimal negative changes in a swine model.

Radiofrequency ablation in a porcine liver model: effects of transcatheter arterial embolization with iodized oil on ablation time, maximum output, and coagulation diameter as well as angiographic characteristics.

AIM: To evaluate the effects of combined radiofrequency ablation and transcatheter arterial embolization with iodized oil on ablation time, maximum output, coagulation diameter, and portal angiography in a porcine liver model. METHODS: Radiofrequency ablation (RFA) was applied to in vivo livers of 10 normal pigs using a 17-gauge 3.0 cm expandable LeVeen RF needle electrode with or without transcatheter arterial embolization (TAE) with iodized oil (n=5). In each animal, 2 areas in the liver were ablated. Direct portography was performed before and after RFA. Ablation was initiated at an output of 30 W, and continued with an increase of 10 W per minute until roll-off occurred. Ablation time and maximum output until roll-off, and coagulated tissue diameter were compared between the 2 groups. Angiographic changes on portography before and after ablation were also reviewed. RESULTS: For groups with and without TAE with iodized oil, the ablation times until roll-off were 320.6 +/- 30.9 seconds and 445.1 +/- 35.9 seconds, respectively, maximum outputs were 69.0 +/- 7.38 W and 87.0 +/- 4.83 W and maximal diameters of coagulation were 41.7 +/- 3.85 mm and 33.2 +/- 2.28 mm. Significant reductions of ablation time and maximum output, and significantly larger coagulation diameter were obtained with RFA following TAE with iodized oil compared to RFA alone. Portography after RFA following TAE with iodized oil revealed more occlusion of the larger portal branches than with RFA alone. CONCLUSION: RFA following TAE with iodized oil can increase the volume of coagulation necrosis with lower output and shorter ablation time than RFA alone in normal pig liver tissue.

[Low-output radiofrequency ablation combined with transcatheter arterial oily-chemoembolization for hepatocellular carcinoma].

We devised low-output radiofrequency ablation (RFA)combined with transcatheter arterial chemoembolization using iodized oil mixed with anticancer drugs (TACE) for hepatocellular carcinoma (HCC), to reduce the cooling effect of tumoral arterial blood flow, to prevent intraportal disseminations and intrahepatic metastases by sudden ebullition (bumping), and to obtain an adequate margin of safety. We performed low-output RFA on 10 HCC patients. We performed RFA with a lower output of 90W or less within two weeks after TACE. After the ablation, portal venous-phase CT images showed a low-density margin of 5 mm or larger around the site of iodized-oil accumulation, indicating that the necrotic area completely included the tumor. No intrahepatic metastasis or severe complication occurred. Low-output RFA combined with TACE is a safe, effective therapy for HCC.