Ethanol Embolization of Chest Wall Arteriovenous Malformations: Four-Year Findings.

OBJECTIVES: To summarize the clinical characteristics and investigate the efficacy of ethanol embolotherapy in the treatment of chest well arteriovenous malformation (AVM). Treatment-associated complications were also explored. MATERIALS AND METHODS: Between March 2017 and August 2021, 32 consecutive patients (mean age, 23.7 years; age range, 5-54 years) who underwent ethanol embolotherapy for chest well AVMs under general anesthesia were included in this study. Embolization was performed through a direct puncture, transarterial catheterization, or a combination of the 2 procedures. The mean follow-up duration after the last treatment was 18.0 months (range, 3-42 months). The degree of devascularization on follow-up (assessed using angiography or computed tomography), and the clinical signs and symptoms of AVMs were evaluated as the therapeutic outcomes. The major and minor complications associated with the procedures were recorded. RESULTS: A total of 103 embolization procedures (mean, 3.2; range, 2-7) comprising 101 ethanol embolization and 2 coil embolizations were performed on 32 patients with chest wall AVMs. The AVM nidus was accessed through the transarterial approach alone in 4 patients, by direct puncture in 11, and a combined procedure in 17 patients. Overall, more than 80% of the procedures were performed using the combined approach. Complete AVM devascularization was achieved in 12 (37.5%) patients. Moreover, 76% to 99% AVM was achieved in 18 patients (56.3%), and 50% to 75% in 2 patients (6.3%). Bleeding, pain, heart failure, and cosmetic deformities were the indications for treatment. For 3 patients (3/32, 9.4%) who had bleeding, the treatment stopped the hemorrhage. Complete pain relief was reported in 8 patients (8/32, 25.0%), whereas complete relief from congestive heart failure post-embolization was observed in 5 of the 6 patients with congestive heart failure (5/6, 83.3%). Complete correction of cosmesis deformities after embolization was achieved in 10 patients (10/32, 31.3%). Two patients who underwent surgery to correct persistent deformity after embolization only showed insignificant improvement. In addition, 6 (18.8%) patients developed 13 complications including blister, necrosis, hemothorax, transient hemoglobinuria, and transient pulmonary artery hypertension. CONCLUSIONS: Ethanol embolotherapy is a safe and effective procedure for chest well AVMs. Surgery is required for some patients with residual cosmesis deformity. CLINICAL IMPACT: Currently, there is no standard treatment for chest well AVMs due to their rarity and high heterogeneity. The present study shows that thanol embolotherapy is a safe and clinically effective treatment procedure for the chest well AVMs. Transarterial embolization in combination with direct puncture embolization can reach the AVM nidus. Ethanol embolotherapy can achieve complete obliteration of the AVM nidus in the majority of patients. Surgery may still be needed to correct cosmetic deformity after embolization. The present study provides valuable evidence to inform clinical decision-making.

Transsinusal embolization of transverse sigmoid sinus dural arteriovenous fistula in a hybrid operating room: A technical note.

BACKGROUND: Using the transverse sinus as a conduit to treat a transverse sigmoid sinus dural arteriovenous fistula is uncommon. This report describes a minimally invasive direct puncture technique for the transverse sinus to treat a complex dural arteriovenous fistula in a hybrid operating room. CASE: The patient was a 64-year-old man with intractable status epilepticus. Digital subtraction angiography demonstrated a right transverse sigmoid sinus dural arteriovenous fistula (Borden type II, Cognard type IIa+b). We performed a transcranial direct puncture because the femoral vein approach was not feasible due to bilateral thrombosed sinuses. Under general anesthesia and park-bench patient positioning, the transverse sinus was exposed and catheterized, and the affected sinus was embolized using microcoils. The fistula was completely obliterated, resolving the status epilepticus. CONCLUSIONS: Direct puncture of the transverse sinus can be effective for treating a transverse sigmoid sinus dural arteriovenous fistula. In a hybrid operating room, combined treatments can be performed comfortably and safely in a single session of general anesthesia. This treatment option is a viable alternative when other methods are unsuccessful.

Successful balloon valvuloplasty using direct puncture of the heart for pentalogy of Cantrell with complete ectopia cordis, low birth weight, single ventricle and severe pulmonary stenosis.

We present a 31 gestational weeks' premature baby whose fetal echocardiogram showed ectopia cordis, single ventricle and severe pulmonary stenosis. At 31 gestational weeks, an emergency caesarean section was performed, and his birth weight was 1756 g, SpO2 was 80% on 100% O2. Epicardial echocardiogram showed double inlet right ventricle, severe valvular pulmonary stenosis and no ductus arteriosus. The risk of surgery was very high, so we decided to perform balloon valvuloplasty by direct puncture of the heart. We punctured the apex of the ventricle using a 16-gauge needle under echo guidance, advanced the guidewire to the pulmonary artery and performed balloon valvuloplasty. Soon after the procedure, the cyanosis improved dramatically. This is the first report of a transcatheter procedure performed by direct puncture of the heart for ectopia cordis with complex congenital heart disease.

Complete embolization of jugular paragangliomas by direct puncture. Technical note.

Objective: Intra-arterial embolization of jugular paragangliomas is an established endovascular technique. Intratumoral embolization by direct puncture has been proposed, prior to surgical treatment or radiosurgery to reduce the risk of cranial nerve deficits. Methods: We examined the technical aspects of two patients with jugular paragangliomas embolized with liquid embolic agent by direct puncture of the lesion, as sole treatment. Results: Two patients with jugular paragangliomas presented with lower cranial nerve deficits. The first patient showed an extended lesion (55-mm) and was treated with partial intra-arterial embolization plus direct puncture and injection of Squid 18 and a second staged embolization by direct puncture and filling of the remainder of the lesion. The second patient with a smaller jugular paraganglioma (33-mm) was treated by single embolization by direct puncture of the tumor and injection of Squid 12 and Squid 18 obtaining complete filling of the lesion. No procedural complications were observed. Both patients showed no residual and initial improvement of the neurological deficits. Conclusion: The intratumoral embolization by direct puncture of jugular paragangliomas, under accurate radiological control is a safe procedure, and complete exclusion of the lesion can be obtained in selected cases. A staged particle embolization of the lesion by direct puncture can be proposed for large lesions. Only further studies with larger series and long-term follow-up will be able to define, if this strategy can be curative avoiding additional surgical or radio-surgical treatment.

Sclerotherapy of peripheral low-flow vascular malformations: technical aspects and mid-term clinical outcome.

PURPOSE: The therapeutical management of low-flow vascular malformations (LFVMs) is challenging because of high recurrence rate; multiple strategies have been proposed. This paper aims to report a single-center experience of direct puncture sclerotherapy of peripheral LFVMs, focusing on technical aspects and clinical outcome in mid-term follow-up. MATERIALS AND METHODS: 16 patients have been treated for peripheral LFVMs (mean age 36.1 years), complaining mild pain, swelling of the region of interest, and cosmetic nuisance. Preprocedural US and MR were acquired; angiography performed only in doubt vascular supply. Standard procedure consisted of direct puncture of the nidus using 20-23 gauge needles under US guidance and injection of up to 15 ml foam of sodium tetradecyl sulphate under fluoroscopic guidance. Clinical and radiological follow-up were assessed at 1, 3, and 6 months. RESULTS: Lesions were localized: 8 in the upper and 5 the in lower limbs, 2 in the cheeks, and 1 in the vaginal labia. All procedures have been technically accomplished (100%). At 6 month follow-up, technical and clinical success were obtained in all cases, while radiological follow-up showed 81.2% (13 patients) complete vessels thrombosis after multiple sclerotherapy sessions. No major complications have been recorded; five patients (31.2%) referred minor complications. CONCLUSIONS: Sclerotherapy via direct puncture of LFVMs is a clinically effective procedure, well tolerated by patients, with reduced costs and mild minor complications rate; interventionalists should always clarify to the patients that multiple sessions would be performed and recurrences are expected at imaging follow-up despite clinical improvement.

Preoperative endovascular embolization of meningiomas: update on therapeutic options.

In this review paper the authors analyze new therapeutic options for the embolization of meningiomas, as well as the future of meningioma treatment through recent relevant cohorts and articles. They investigate various embolic materials, types of meningiomas amenable to embolization, imaging techniques, and potential imaging biomarkers that could aid in the delivery of embolic materials. They also analyze perfusion status, complications, and new technical aspects of endovascular preoperative embolization of meningiomas. A literature search was performed in PubMed using the terms "meningioma" and "embolization" to investigate recent therapeutic options involving embolization in the treatment of meningioma. The authors looked at various cohorts, complications, materials, and timings of meningioma treatment. Liquid embolic materials are preferable to particle agents because particle embolization carries a higher risk of hemorrhage. Liquid agents maximize the effect of devascularization because of deeper penetration into the trunk and distal tumor vessels. The 3 main imaging techniques, MRI, CT, and angiography, can all be used in a complementary fashion to aid in analyzing and treating meningiomas. Intraarterial perfusion MRI and a new imaging modality for identifying biomarkers, susceptibility-weighted principles of echo shifting with a train of observations (SW-PRESTO), can relay information about perfusion status and degrees of ischemia in embolized meningiomas, and they could be very useful in the realm of therapeutics with embolic material delivery. Direct puncture is yet another therapeutic technique that would allow for more accurate embolization and less blood loss during resection.

Treatment of tongue cavernous haemangioma with direct puncture and sclerotization with ethanol.

BACKGROUND: Haemangiomas of tongue are rare type of malformations. They can be treated mostly conservatively but in some cases they need more aggressive treatment with preoperative intra arterial embolization and surgical resection. Lesions of tongue that are localized superficially can also be treated with direct puncture and injection of sclerosing agent (absolute ethanol). CASE REPORT: We present a case of a 48 years old female patient, where we performed embolization of cavernous haemangioma with mixture of absolute ethanol and oil contrast. After the procedure the patient received analgetics and antioedematous therapy. After the sclerotization the planed surgery was abandoned. Control MRI examinations 6 and 12 months after the procedure showed only a small remnant of haemangioma and no signs of a larger relapse. CONCLUSIONS: In our case the direct puncture of haemangioma and sclerotherapy with ethanol proved to be a safe and effective method to achieve preoperative devascularization of the lesion. Direct puncture of the lesion is not limited by the anatomy of the vessels or vasospasm, which can occur during the intra-arterial approach.

Combined DSA- and US-guided management of acute bleeding: effectiveness of percutaneous glue embolization in six cases.

AIMS: This study aims to report on safety and effectiveness of glue embolization of acute hemorrhages performed by US-guided percutaneous direct puncture, in patients where the standard endovascular approach is technically unfavourable. METHODS: In this single center retrospective analysis, patients affected by traumatic or non traumatic acute hemorrhages were treated with glue embolization technically performed by US-guided direct puncture. Patients suffered from active bleeding detected at contrast-enhanced Computer Tomography and confirmed at Digital Subtracted Arteriography, with concomitant hemoglobin drop and blood pressure reduction. Six patients were reviewed; hemorrhages occurred in liver parenchima (1), gallbladder (1) and lower limbs (4). Bleedings etiologies were post-traumatic (5) and inflammatory (1); four had extraluminal blushes while 2 were pseudoaneurysms. In five cases (4 limbs and 1 hepatic bleedings) the direct-puncture approach was adopted because of technically unfavourable vascular anatomy for superselective embolization; in one case (cystic artery pseudoaneurysm), an endovascular embolization would entail a high risk of gallbladder ischemia because of its terminal arterial supply. Technical success was defined disappearance of bleeding signs at last arteriography; clinical success was considered stabilization and/or improvement of hemoglobin values and arterial pressure without additional interventions. RESULTS: Both technical and clinical successes were obtained in 100% of the cases without major complications. No needle occlusion occurred during glue injection. CONCLUSIONS: In this study percutaneous US-guided embolization by direct puncture was a safe and effective approach to manage acute bleedings; it could be considered as an alternative in patients with unfavourable vascular anatomy for the standard catheter-directed endovascular embolization.

Pseudoaneurysms embolization with glue via percutaneous direct puncture: a multicenter experience on 54 patients.

BACKGROUND: This retrospective multicentric study aims to report on technical safety and effectiveness of pseudoaneurysms embolization with glue (N-butyl cyanoacrylate) adopting a percutaneous direct puncture approach. RESULTS: Fifty-four patients data were collected from five centers. All patients at the time of treatment presented with unruptured PAs and were hemodynamically stable. True aneurysms and lesions treated with embolics other than glue were excluded. Pseudoaneurysms diagnosis was based on CT and anamnestic data; initial investigation with digital-subtracted arteriography was acquired in all cases; then, percutaneous embolizations were performed in the angio-suite (ultrasound, fluoroscopy, ConeBeam CT guidance) or in CT. Technical success was considered as complete pseudoaneurysm embolization at final imaging with sole percutaneous strategy, without need for additional endovascular embolization. Clinical success was intended as pseudoaneurysm resolution within one week follow-up with stabilization or restored clinical conditions. Pseudoaneurysms origins were traumatic (57.4%), inflammatory (24.1%) or spontaneous (18.5%); 39 patients (72.2%) were symptomatic, presenting with pain and/or pulsatile mass. Mean lesions diameter was 19.3 mm (range: 7-30); pseudoaneurysms were located in abdomen (48.1%), limbs (42.6%) and thorax (9.3%). Coagulation function was impaired in 16.6% and 48.1% was under antiplatelets/anticoagulation therapy. In 16.6% the percutaneous approach followed previous treatments failure. The image-guidance modality for percutaneous puncture was most often ultrasound combined with fluoroscopy (38%). Clinical success was obtained in all patients while technical success occurred in 94.4% because 3 patients required an additional endovascular embolization. Complications were registered in 14.8%, all of low grade without clinical sequelae neither prolonged recovery (7 non target embolizations, 1 post-embolization syndrome). CONCLUSIONS: In this study, pseudoaneurysms embolization with glue via percutaneous direct puncture was safe and effective with a low rate of minor complications.

Combined Direct Tumoral Puncture Embolization with Onyx and Trans-arterial Embolization for JNA.

Onyx is a safe and effective embolic agent to utilize in the treatment paradigm of JNA. We present a tandem approach that combines trans-arterial embolization (TAE) with direct puncture embolization (DPE) with Onyx to limit blood loss and facilitate safe resection. Laryngoscope, 134:3568-3571, 2024.

Preoperative Direct Puncture Embolization Using a Nonadhesive Ethylene Vinyl Alcohol (EVOH) Liquid Embolic Agent for Head and Neck Paragangliomas.

PURPOSE: This retrospective study aimed to assess the safety and technical efficacy of preoperative direct puncture embolization using a nonadhesive ethylene vinyl alcohol (EVOH) copolymer-based liquid embolic agent (LEA) combined with balloon occlusion at the origin of the external carotid artery for head and neck paragangliomas (HNP). METHODS: We conducted a review of all consecutive cases of HNPs treated with direct puncture embolization using EVOH-based LEAs between 2017 and 2022 in 2 tertiary high-volume hospitals. RESULTS: A total of 25 cases of HNPs in 24 patients underwent direct puncture embolization (12 males, 12 females, mean age 50.9 ± 15.6 years). The average lesion volume was 299.95 mm3. The mean procedure time was 139.11 min, and the mean volume of EVOHs used per case was 19.38 mL. Successful complete devascularization was achieved in all cases, with a homogeneous and deep penetration of the embolic agent into the tumor vessel bed regardless of the LEA type. CONCLUSION: Preoperative embolization of HNPs using a direct puncture technique and EVOHs is a safe, efficient, and feasible treatment option with a low risk of complications. This procedure facilitates surgery by transforming tumors into avascular masses that are well-delineated against the surrounding normal tissue.

A cavernous sinus dural arteriovenous fistula treated by direct puncture of the superior ophthalmic vein with craniotomy: illustrative case.

BACKGROUND: The authors report a case of symptomatic cavernous sinus (CS) dural arteriovenous fistula (dAVF) that was successfully treated using direct puncture of the superior ophthalmic vein (SOV) with craniotomy. CS dAVF is commonly treated using transvenous embolization (TVE), with the most common access route via the inferior petrosal sinus (IPS). However, this route is sometimes unavailable because of an occluded, hypoplastic, aplastic, or tortuous IPS. The SOV is an alternative, albeit tortuous and long, route to the CS; therefore, direct SOV puncture is occasionally performed. Direct SOV puncture is mostly percutaneous; however, in this case, it was difficult because of subcutaneous SOV narrowing. OBSERVATIONS: As the patient experienced increased intraocular pressure, decreased vision, and eye movement disorders, CS embolization was performed via direct puncture with a craniotomy because of other access difficulties. LESSONS: Several reports have described CS dAVF in patients receiving endovascular treatment via direct SOV puncture using a transorbital approach. However, to the best of the authors' knowledge, this is the first reported case of a CS dAVF treated using TVE with craniotomy. This approach is useful when the SOV cannot be reached intravenously and its distance from the epidermis is long.

The Role of Preoperative Onyx Embolization by Transnasal Direct Puncture in the Treatment of an Advanced Juvenile Nasopharyngeal Angiofibroma.

Juvenile nasopharyngeal angiofibroma (JNA) is a rare and locally aggressive tumor that commonly presents with painless nasal obstruction and severe, recurrent epistaxis. In this case report, we describe the successful management of a Radkowski stage IIIA JNA with extensive arterial supply from the internal carotid artery (ICA). Transnasal direct puncture embolization using Onyx (Medtronic, Minneapolis, Minnesota) was employed to effectively devascularize the tumor, enabling radical surgical resection in a single piece via endonasal and transmaxillary endoscopic approaches. The patient did not require blood transfusion and was discharged without neurological impairment. The effectiveness of preoperative embolization as a treatment strategy for JNA is also discussed.

Percutaneous Puncture Embolization for Recurrent Pulmonary Arteriovenous Malformation After Failed Initial Treatment: A Case Report.

BACKGROUND: Transcatheter embolization is a commonly used minimally invasive technique in the treatment of pulmonary arteriovenous malformation (PAVM) with a high probability of post-operative recurrence, and some recurrent cases of PAVM cannot be treated via pulmonary arterial re-embolization. Here, we report the first case, to our knowledge, a 55-year-old female undergoing percutaneous direct puncture embolization for recurrent PAVM with good short-term efficacy. CASE PRESENTATION: The patient was a 55-year-old female presenting to the emergency department of our hospital with acute exacerbation of chest tightness and shortness of breath for 2 hours. The patient was diagnosed with PAVM and undergone embolization half a year ago. DSA-guided embolization was performed through percutaneous puncture approach. After embolization with four spring coils, the blood flow to the PAVMs was stopped and the surgery completed. The patient reported improvement of chest tightness and shortness of breath and was discharged from the hospital 3 days later. CONCLUSION: Our case was unique as a portion of the PAVMs was closely attached to the chest wall and PVP was slightly increased, which made percutaneous puncture embolization possible. Our case can be helpful in the treatment of recurrent PAVM in patients who cannot undergo re-embolization through pulmonary artery.

Embolization of Deep Femoral Artery Aneurysm with a Ligated Proximal Artery Using the Direct Percutaneous Puncture Technique.

We report a case of a deep femoral artery aneurysm with a ligated proximal artery that was successfully managed with endovascular therapy. An 84-year-old male was referred to our institute with a history of surgical resection of a left ruptured deep femoral artery aneurysm wherein another aneurysm was found on the peripheral side. Proximal artery ligation of the peripheral lesion was performed. The residual aneurysm had gradually enlarged after surgery, and contrast-enhanced computed tomography showed contrast effects in the aneurysm that extended to the distal artery. The aneurysm was successfully treated by direct percutaneous puncture embolization with N-butyl-cyanoacrylate.

Direct puncture of an occluded common femoral artery as a new approach for endovascular aortic aneurysm repair.

BACKGROUND: Abdominal aortic aneurysms (AAA) which present with a hostile access are not uncommon. When an arterial occlusion continuously involves from the iliac to the femoropopliteal artery, endovascular aneurysm repair (EVAR) can become complex, necessitating an adjunctive surgical procedure. The present report outlines a successful EVAR which was conducted without any adjunctive surgical procedure for an AAA complicated by extensive access vessel occlusion. CASE PRESENTATION: The patient, an 82-year-old male, had a fusiform 50 mm infrarenal AAA. He had a history of above knee amputation of the right leg due to a gangrene from Buerger's Disease. Despite the continuous occlusions of the right external iliac artery (EIA), common femoral artery (CFA), and superficial femoral and profunda femoris artery, limb ischemia was not observed in his right leg. Since revascularization of the occluded right iliac and femoral arteries was deemed to be too complex technically and no ischemic symptoms were observed, EVAR was performed using the occluded access only for the delivery of the stent graft without restoring the flow. Firstly, the occluded right CFA was punctured under ultrasound guidance. Next, a 0.014 in. guidewire and a microcatheter were successfully navigated to the subintimal space of the right common iliac artery (CIA), these were then exchanged with a reentry device. The reentry device allowed the advancement of a guidewire into the true lumen of the right CIA. Then, a 12Fr sheath for delivery of a contralateral limb was advanced via the occluded right access to aorta, and a 16 Fr sheath for delivery of a main body graft was advanced via a patent left iliac artery. A standard EVAR procedure was subsequently performed. CONCLUSIONS: EVAR was successfully performed for an AAA complicated with an arterial occlusion from the EIA to the SFA using direct puncture of the occluded CFA. This technique could be an effective measure for cases with a hostile access involving the CFA.

Transcatheter embolization for stomal varices: A report of three patients.

Stomal varices are rare and ectopic varices defined as dilated portosystemic collateral veins located in sites other than the gastro-esophageal region. These sometimes cause recurrent bleedings and can be life-threatening. Optimal treatments have yet to be established. We report 3 cases of repetitive bleeding stomal varices in which resolution of bleeding was obtained over the medium term with minimally invasive approaches including balloon-occluded retrograde transvenous obliteration and variceal embolization by ultrasound-guided direct puncture. Rebleeding did not occur in any patients within 2-15 months of follow-up. Serious complications over Clavien-Dindo grade I were not found.

Direct Vertebral Artery Puncture During Open Surgery for the Endovascular Treatment of a Recurrent Vertebro-Vertebral Arteriovenous Fistula.

BACKGROUND: Vertebro-vertebral arteriovenous fistula (VVAVF) is a condition in which there is an arteriovenous shunt directly connecting the extracranial vertebral artery to the vertebral venous plexus. Many reports have described fistula occlusion or vertebral artery trapping as treatments for VVAVF. Here, we describe a case in which endovascular treatment for recurrent VVAVF using a transfemoral approach was unsuccessful; thus, the vertebral artery (VA) was directly punctured during open surgery and the treatment was successful. CASE DESCRIPTION: The patient was a 47-year-old female who had undergone endovascular treatment for VVAVF. The patient developed subarachnoid hemorrhage. Digital subtraction angiography revealed a left VVAVF. The left VA was trapped with coils at the C2 and C3 levels and an arteriovenous shunt formed from the VA between the 2-coil mass to the vertebral venous plexus. In addition, reflux was observed in the spinal vein. Endovascular treatment was attempted with a transfemoral approach, but we could not reach the shunt. Five days post-treatment, the patient had a second subarachnoid hemorrhage and surgery was performed to occlude the radiculomedullary vein; however, residual reflux went into the spinal vein from another spinal level. Later, the VA was directly punctured and treated with N-butyl cyanoacrylate, and the shunt disappeared. CONCLUSIONS: Direct puncture of the vertebral artery was useful in this case, where it was difficult to reach the lesion. Although direct VA puncture is associated with more complications than the transfemoral or transbrachial approach, it may be an option when other methods are difficult.

Usefulness of an Electromagnetic Navigation System for Direct Percutaneous Puncture of the Superior Ophthalmic Vein.

Objective: We report a case of dural arteriovenous fistula (dAVF) at the cavernous sinus treated by direct puncture of the superior ophthalmic vein (SOV) using an electromagnetic navigation system. Case Presentation: The case involved a 70-year-old male patient who presented with mild chemosis, proptosis, and abducens palsy of the right eye. In this case, we used an electromagnetic navigation system for direct puncture of the SOV. Angiographic obliteration of the fistula was confirmed and the visual symptoms recovered well after surgery. There were no complications associated with direct puncture of the SOV using the electromagnetic navigation system. Conclusion: Direct puncture of the SOV to obliterate a dAVF is a possible alternative choice of treatment when the usual transvenous access route fails. To reduce the risk of complications, an electromagnetic navigation system is useful.

Preoperative Squid embolization of carotid paragangliomas with direct puncture.

BACKGROUND AND PURPOSE: Preoperative embolization of carotid paragangliomas is a common procedure in interventional neuroradiology. Direct puncture embolization has shown less morbidity and mortality than endovascular embolization and a higher percentage of devascularization. We describe our experience using Squid® as the only embolic agent in direct puncture glomus embolization. METHODS: We retrospectively reviewed pre-embolization imaging tests, emphasizing the volume of the lesion, clinical history data, technical aspects of the procedure, as well as the approximate amount of blood lost during the surgical procedure in all patients with preoperative embolization of carotid paragangliomas performed at our tertiary care hospital. RESULTS: Six patients met our criteria from May 2017 to August 2018. The volume of the mass ranged from 1.4-18.5 mL and the quantity of Squid® injected varied from 1.1-15 mL. Total devascularization was achieved in almost all cases (>90%), with one puncture needed in all but one patient, who was punctured two times. No hemorrhagic complications were described in surgery, no blood transfusions were needed, and the mean decrease of hemoglobin after surgery was 1.04 g/dL. CONCLUSIONS: Direct puncture embolization of carotid paragangliomas only using Squid® is a safe and relatively simple procedure that facilitates the subsequent surgery with minimal blood loss.