evoh-based agents embolization of head and neck vascular
TRANSCRIPT
Embolization of Head and Neck Vascular Malformations Using a Dual Microcatheter Technique
David Case MD, Paul Rochon MD, Christopher Roark MD, Ann Kulungowski MD, Daniel Wells MD, Jason Rich PA, Zach Folzenlogen MD, David Kumpe MD, Joshua Seinfeld MD
David Case
• No relevant financial relationship reported
Objectives
Brief angioarchitecture background
Dual catheter technique
Case series results
Example cases
Cerebral AVMs
http://www.ldtfoundation.org/avm.html
Dural AV fistulas
http://www.cvsection.org/patients/cerebrovascular-diseases/arteriovenous-fistulas-avf/av-fistula-images-207
Previously described dual microcathetertechniques
Chapot et al, The Pressure Cooker Technique for Treatment of Brain AVMs, Journal of Neuroradiology (2014), 41, 87-89
Abud et al, The Modified Pressure Cooker Technique: an easier way to control Onyx reflux, Journal of Neuroradiology 2016
Our technique – Prune, Plug, and Penetrate
“Prune” smaller arterial feeders first
Dominant feeding branch embolizationPosition DMSO compatible microcatheter distally near nidus and a second DMSO compatible microcatheterproximally with tip between distal microcatheter tip and detachment zone
“Plug” formation through proximal microcatheter with Onyx 34(Medtronic, Minneapolis, MN) and coils
“Penetrate” Onyx 18 through distal catheter
Small feeder
Dominant supply
Draining vein
Small feeder
Small feeder
Advantages
Pruning reduces intra-nidal pressure/resistance during embolization of the dominant feeding branch
Provides wedge-flow conditions with proximal Plugformation
Improve distal Penetration of Onyx
Reduce blood flow through fistulous compartments
Avoid Onyx reflux and non-target embolization
Case series summary
Cerebral AVM casesAge Gender Spetzler
MartinLocation Pedicles embolized with
dual catheterResult Follow-up
11 F 2 Left occipital Embolization 2 - Left PCA
No residual-> surgery the next day
No residual at 6 months
17 M 3 Right frontal Embolization 3 - Right ACA
Minimal residual -> gamma knife
No residual at 4 months
34 M 4 Right frontal Embolization 5 - Right ACA
Minimal residual-> surgery the next day
No residual at 1 week
53 F 4 Left occipital Embolization 3 - Left PCA
Minimal residual-> surgery the next day
Pending
16 M 3 Right temporal Embolization 1 - Right PCA and MCA
Minimal residual-> surgery the next day
Pending
Dural AV fistula cases
Age Gender Cognard Pedicles embolized with dual catheter
Result Follow-up
36 M 3 Left occipital and middle meningeal
No residual No residual at 6 months
34 F 2b Right occipital and middle meningeal
Minimal residual No residual at 2 years
88 M 2b Right occipital and left posterior meningeal
Minimal residual Minimal residual at 1 month
Head and Neck AVM cases
Age Gender Location Pedicles embolized with dual catheter
Result Follow-up
10 male Right mandibular
Embolization 1- Right facial and internal
maxillary
No residual No residual at 6 months
15 male Left neck Embolization 2, 4 - Deep cervical and transverse
scapular- Deep cervical and transverse
scapular
Minimal residual Pending
10 female Rightmandibular
Embolization 1 - Right internal maxillary
No residual Pending
Example case 1
A
Left occipital AVM
Pre-embolization right vertebral artery
Left occipital AVM
Proximal(small arrow) and distal(large arrow) microcatheter tips
B
Left occipital AVM
Proximal plug
C
Left occipital AVM
Post-embolization
D
Example case 2
Right mandibular AVM
Pre-embolization right external carotid artery
A
Right mandibular AVM
Proximal(vertical arrow) and distal(horizontal arrow) microcatheter tips positioned in inferior alveolar artery
B
Right mandibular AVM
Proximal plug
C
Right mandibular AVM
Post-embolization right external carotid artery with no residual
D
References1. Abud et al, The Modified Pressure Cooker Technique: an easier way to control Onyx reflux,
Journal of Neuroradiology 2016.
2. Abud DG, Riva R, Nakiri GS, et al. Treatment of brain arteriovenous malformations by double arterial catheterization with simultaneous injection of Onyx: aretrospective series of 17 patients. Am J Neuroradiol 2011;32(1):152—8.
3. Chapot et al, The Pressure Cooker Technique for Treatment of Brain AVMs, Journal of Neuroradiology (2014), 41, 87-89.
4. Weber W, Kis B, Siekmann R, et al. Endovascular treatment ofintracranial arteriovenous malformations with onyx: technicalaspects. Am J Neuroradiol 2007;28(2):371—7.
5. Saatci I, Geyik S, Yavuz K, Cekirge HS. Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course. J Neurosurg2011;115(1):78—88.
Questions