Technical Note
A method for complete angiographic obliteration of a brain arteriovenous malformation in a single session through a single pedicle

https://doi.org/10.1016/j.jocn.2014.07.030Get rights and content

Abstract

Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been relegated to an adjunctive role to open surgical and radiosurgical methods. In this article, we describe a novel endovascular approach to the treatment of brain AVM using Onyx (ev3 Endovascular, Plymouth, MN, USA), which may allow for a complete angiographic obliteration in a single treatment session. Twelve patients underwent Onyx embolization of an AVM using a novel “reverse plug and push” technique in which a plug is formed around the treatment catheter prior to injecting Onyx into the AVM. The plug mitigates the risk of backflow and catheter entrapment, thereby allowing the user to inject higher volumes of Onyx at higher injection rates. Patient demographics, AVM characteristics, and treatment details were reviewed. Using the “reverse plug then push” technique, an average of 8.8 mL of Onyx was injected into the AVM in a single session. In every case, the microcatheter was removed easily with minimal traction pressure. Complete angiographic obliteration was achieved in 83% of patients after a single treatment. Morbidity and mortality were 8% each. The “reverse plug then push” technique allows for a more rapid injection of Onyx due to the formation of a well-controlled plug prior to treatment, mitigating the risk of catheter entrapment by Onyx reflux. With further refinement, this technique may present a viable curative option for treatment of select brain AVM.

Introduction

After the US Food and Drug Administration approved Onyx (ev3 Endovascular, Plymouth, MN, USA) in 2005 for the preoperative embolization of brain arteriovenous malformations (AVM), it soon became clear that some brain AVM could be cured with this material. Not only is Onyx non-adhesive, but it is easier to handle, is less inflammatory, and has a longer working time than n-butyl cyanoacrylate (nBCA) [1]. Although it is non-adhesive, the cohesive nature of Onyx can cause functional entrapment of the microcatheter during injection, increasing the risk of complications related to removing the catheter and decreasing the degree of nidal penetration that can safely be achieved. The concern of entrapment has limited the ability to provide curative embolization of brain AVM using Onyx. The recent literature reports curative embolization rates ranging from 10 to 55% using Onyx [2], [3], [4], [5], [6], [7], [8], [9], [10].

This paper describes an endovascular technique for Onyx embolization of brain AVM, termed the “reverse plug then push” technique, which entails the retrograde formation of a well-controlled plug around the delivery catheter prior to pushing Onyx forward into the AVM. This technique is to be distinguished from the traditional plug then push technique whereby a plug is created ahead of the catheter during forward injection of Onyx, which can lead to uncontrolled reflux around the microcatheter tip. The “reverse plug then push” technique helps prevent unwanted reflux around the treatment catheter, reducing the concern for catheter entrapment. Since the reflux around the catheter tip is greatly reduced, better penetration of the AVM nidus is possible, increasing the likelihood of angiographic obliteration. In this paper, we describe the technique and subsequent results in 12 patients treated with the “reverse plug then push” technique with intent to cure the AVM.

Section snippets

Study design

Under the approval of our Institutional Review Board, we performed a retrospective chart review identifying 12 patients who underwent brain AVM embolization with curative intent using a “reverse plug then push” technique with Onyx. Patient demographics, radiographic records, and treatment reports were independently reviewed by a member of the research team who was not part of the treatment team.

Procedure

All procedures were performed under general anesthesia by a single interventional neuroradiologist

Patient demographics

Twelve patients underwent Onyx embolization of a brain AVM using the “reverse plug then push” technique. The average age was 44.3 years, and 67% of the patients were male (Table 1). Seven of the 12 patients (58%) presented with subarachnoid hemorrhage. Of the patients with unruptured AVM, all were symptomatic. Three patients (25%) presented with severe headaches, two (17%) of whom also had a visual field deficit. One patient (8%) had a hemisensory deficit. One patient (8%) presented with new

Discussion

Reflux of Onyx using traditional techniques can entrap the catheter, preventing safe retrieval at the termination of the procedure or necessitating removal of the catheter before the nidus can be completely obliterated. Using the “reverse plug then push” technique, a very controlled, short segment plug is formed near the tip of the treatment microcatheter (Fig. 2). Controlling the size of the plug prior to initiating treatment has several advantages. First, it helps prevent reflux. Second, the

Conclusion

Using the “reverse plug then push” technique in this small group of patients, it was possible to achieve complete angiographic obliteration in 83% of the patients. This paper and Abud’s work suggest that in well selected cases, attempts at a single session cure may be a reasonable alternative to staged procedures. Now that it may be possible to completely obliterate AVM in a single session, it remains to be seen if it is wise to do so.

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

Acknowledgements

Funding was generously provided to the senior author, Avery Evans, by the For The Love of Molly Foundation, Richmond, VA, USA. The study sponsor played no role in the study design, analysis or interpretation of the data, writing the report, or the decision to submit the paper for publication. The funding was used as salary support for the researcher while collecting and analyzing the data and writing the paper.

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