EVOH-based Agents Embolization of Head and Neck Vascular ...

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