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  • Endovascular Techniques for Safe Pre-operative Embolization of Juvenile Angiofibroma – Avoiding the Pitfalls of ECA-ICA Anastomosis, Increasing Extent of Embolization, and Reducing Intra-Operative Blo

    Final Number:

    David Rosenbaum-Halevi MD; Ali Turkmani MD; Peng Roc MD Chen

    Study Design:

    Subject Category:
    Vascular Malformations

    Meeting: AANS/CNS Cerebrovascular Section 2018 Annual Meeting

    Introduction: Juvenile-nasopharyngeal-angiofibroma (JNA) is a rare benign neoplasm of the nasopharynx most commonly presenting in adolescent males. Surgical resection of this hyper-vascular tumor is facilitated by pre-operative embolization to minimize surgical blood loss – avoiding complications, and increasing the extent of resection. Embolization is complicated by multiple ECA-ICA anastomosis, and failure to address these anastomosis with safe technique can result in embolic stroke and suboptimal embolization results. We describe a sophisticated balloon assisted embolization technique in which a balloon (Hyperglide 5X30mm) is inflated in the ICA from C2-C4 during Onyx-34 injection through ECA tumor feeders, effectively sealing the ICA circulation from embolic material.

    Methods: 13 consecutive cases who underwent JNA embolization between 2008-2015 were identified. Demographic, clinical, and outcome data were reviewed for analysis.

    Results: All patients in the study were males aged 9-29 yrs. (mean 14.9yrs.). All tumors were embolized with Onyx-34 in a single session. Selective embolization of multiple vessels was required in all cases to achieve maximal result. An average 81% embolization (60-100%) was achieved overall, with >80% embolization in 6 cases and >90% embolization in 4. There were no complications or morbidities secondary to embolization. Gross-total and Near-total resection was achieved in 33.3% of cases, minimal residual (10%) in 41.7 %, and partial resection in 25%. Average total surgical blood loss was 1500ml (250-4500ml). All but one case required blood derivative or colloid resuscitation. Average surgical resection time was 290 min. (127-535min.). There were no surgical complications with exception of one case requiring repeat embolization for excessive bleeding. One patient experienced mild delayed onset facial weakness, otherwise no surgical morbidities were noted.

    Conclusions: Balloon protection of ICA circulation while injecting ECA branches for JNA embolization reduces procedural complications, and allows for more aggressive and complete embolization. This results in more extensive tumor resection and minimizes surgical blood loss.

    Patient Care: Implementation of the technique described will reduce iatrogenic embolic strokes and increase extent of tumor embolization. As result there will be less surgical complications and more complete tumor resection. Thus significantly improving patient treatment outcome.

    Learning Objectives: By the conclusion of this session participants should be able to 1)Understand the unique vascular anatomy created by ICA-ECA anastomosis 2) Understand complications associated with JNA embolization and resection due to vascular anatomical considerations 3) Review a novel surgical technique to avoid complications 4)Apply this new information such that the experienced operator can attempt to incorporate this technique in clinical practice 5) Apply these concepts to other situations of dangerous anastomosis


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