Introduction: Embolization of hypervascular lesions requires making a “proximal plug” to allow forward penetration of the embolic material while preventing reflux into areas to be preserved. This can be difficult and can increase procedure time and result in extensive fluoroscopy use and radiation exposure to the patient and operator. Common techniques require adjuncts such as coils, the use of catheters with breakable tips, varying liquid embolic formulation for longer or shorter working times, and abrupt catheter withdrawal. We reviewed our experience with balloon-augmented Onyx embolization of hypervascular cranial, neck and spinal lesions using a double lumen balloon microcatheter technique to minimize these challenges.
Methods: We performed a consecutive case series retrospective evaluation of all procedures utilizing a dual lumen balloon to assist with Onyx embolization. Cases were performed by a group of two Neurointerventional Radiologists or two Neurosurgeons at a single institution between April 2012 and December 2015. For each procedure, at least one double lumen balloon catheter was advanced to a main feeder and Onyx embolization was performed through the inner lumen while the balloon was kept inflated.
Results: 103 patients met inclusion criteria using 152 balloons, and 454 preparations of Onyx. There were 47 tumors, 34 dural arteriovenous fistulas, 19 arteriovenous malformations, 2 aneurysmal bone cysts, and one case of epistaxis treated. There were no cases with vessel injuries, unwanted embolization/ reflux, retained microcatheters or balloon ruptures. There were no procedural complications in our series.
Conclusions: Embolization of brain AVMs with Onxy has a procedural complication rate between 4%-9% in the literature. Series most often report reflux of embolic material or hemorrhage after microcatheter entrapment by the embolic material as leading Intraprocedural complications. Our experience indicates that the use of dual lumen balloon microcatheters to inject Onyx is safe and facilitates the penetration for embolization of hypervascular lesions (Figure 1).
Patient Care: This project describes a double-lumen balloon technique employed at our facility for embolization of neurovascular tumors, fistulas, and malformations. This procedure can be associated with significant morbidity. Others may also employ this technique but it is important to constantly re-evaluate or experiences and methods collectively and as individuals to seek improvement. This is especially important in endovascular where equipment is constantly evolving which may make older studies obsolete.
Learning Objectives: By the conclusion of this session participants should be able to:
1. Describe common causes of procedural morbidity from Onyx embolization of hypervascular head, neck and spinal abnormalities.
2. Identify embolization strategies that can be employed to decrease the risk of embolic material migration, parent vessel damage and hemorrhage.
References: 1. Abu-Ghanem S, Yehuda M, Carmel NN, Abergel A, Fliss DM. Impact of preoperative embolization on the outcomes of carotid body tumor surgery: A meta-analysis and review of the literature. Head Neck. 2016:n/a. doi:10.1002/hed.24381.
2. Raper DMS, Starke RM, Henderson F, et al. Preoperative embolization of intracranial meningiomas: efficacy, technical considerations, and complications. AJNR Am J Neuroradiol. 2014;35(9):1798–1804. doi:10.3174/ajnr.A3919.
3. Singla A, Deshaies EM, Melnyk V, et al. Controversies in the role of preoperative embolization in meningioma management. Neurosurg Focus. 2013;35(6):E17. doi:10.3171/2013.9.FOCUS13351.