Abstract
Purpose
Insufficient nidus occlusion is a matter of great concern to routine Onyx embolization of brain arteriovenous malformations (AVMs). This paper described an efficient method which using the diluted Onyx embolization technique to treat brain AVM.
Methods
The diluted Onyx technique was performed in a series of 15 patients with brain AVMs (10 males, 5 females; age range, 11–44 years). It consists of initial embolization with routine Onyx-18, followed by the diluted Onyx (1.5 mL of Onyx-18 diluted with 0.5 mL of DMSO) through the same microcatheter. The technical skills and angiographic and clinical outcomes were analyzed.
Results
A total of 15 embolization sessions were performed with diluted Onyx via 16 arterial feeders in these 15 patients. Each patient underwent one attempt of diluted Onyx through a single feeder except one patient. In this patient, the AVM was simultaneously embolized with diluted Onyx through double microcatheters which were placed in two feeders. When the length of reflux reached to 2 cm (or close to the determined length) and the embolic material could not move distally any more despite some rounds of “injection-reflux-waiting,” regular Onyx 18 was changed to diluted Onyx. Antegrade flow of embolic material into the nidus was observed in 12 cases but failed in 3. An average of 90% (range 55–100%) estimated size reduction was achieved, and 6 AVMs were completely obliterated. No functionally relevant complications occurred.
Conclusion
The diluted Onyx technique could be a useful adjunct to routine Onyx embolization which may offer more embolic material penetrating into the nidus of AVM, but additional work is needed to validate this technique.
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Abbreviations
- AVMs:
-
Arteriovenous malformations
- DMSO:
-
Dimethyl sulfoxide
- EVOH:
-
Ethylene-vinyl alcohol copolymer
- PCT:
-
Pressure cooker technique
- SM:
-
Spetzler-Martin
References
Panagiotopoulos V, Gizewski E, Asgari S, Regel J, Forsting M, Wanke I (2009) Embolization of intracranial arteriovenous malformations with ethylene-vinyl alcohol copolymer (onyx). AJNR Am J Neuroradiol 30:99–106
Ellis JA, Lavine SD (2014) Role of embolization for cerebral arteriovenous malformations. Methodist Debakey Cardiovasc J 10:234–239
Plasencia AR, Santillan A (2012) Embolization and radiosurgery for arteriovenous malformations. Surg Neurol Int 3:S90–S104
van Rooij WJ, Sluzewski M, Beute GN (2007) Brain AVM embolization with onyx. AJNR Am J Neuroradiol 28:172–177 178
van Rooij WJ, Jacobs S, Sluzewski M, van der Pol B, Beute GN, Sprengers ME (2012) Curative embolization of brain arteriovenous malformations with onyx: patient selection, embolization technique, and results. AJNR Am J Neuroradiol 33:1299–1304
Fifi J, Niimi Y, Berenstein A (2013) Onyx embolization of an extensive mandibular arteriovenous malformation via a dual lumen balloon catheter: a technical case report. J Neurointerv Surg 5:e5
Jagadeesan BD, Grigoryan M, Hassan AE, Grande AW, Tummala RP (2013) Endovascular balloon-assisted embolization of intracranial and cervical arteriovenous malformations using dual-lumen coaxial balloon microcatheters and onyx: initial experience. NEUROSURGERY 73:s238-s243–s243
Chapot R, Stracke P, Velasco A, Nordmeyer H, Heddier M, Stauder M, Schooss P, Mosimann PJ (2014) The pressure cooker technique for the treatment of brain AVMs. J Neuroradiol 41:87–91
Abud DG, de Castro-Afonso LH, Nakiri GS, Monsignore LM, Colli BO (2016) Modified pressure cooker technique: an easier way to control onyx reflux. J Neuroradiol 43:218–222
Weber W, Kis B, Siekmann R, Kuehne D (2007) Endovascular treatment of intracranial arteriovenous malformations with onyx: technical aspects. AJNR Am J Neuroradiol 28:371–377
Lv X, Wu Z, Jiang C, Li Y, Yang X, Zhang Y, Zhang N (2011) Complication risk of endovascular embolization for cerebral arteriovenous malformation. Eur J Radiol 80:776–779
Jordan JA, Llibre JC, Vazquez F, Rodriguez R, Prince JA, Ugarte JC (2014) Predictors of hemorrhagic complications from endovascular treatment of cerebral arteriovenous malformations. Interv Neuroradiol 20:74–82
Lv X, Wu Z, Li Y (2013) Arteriovenous malformation in the brain: a theoretical study explaining the behavior of liquid embolic agents during endovascular treatment. Neuroradiol J 26:661–668
Akmangit I, Daglioglu E, Kaya T, Alagoz F, Sahinoglu M, Peker A, Derakshani S, Dede D, Belen D, Arat A (2014) Preliminary experience with squid: a new liquid embolizing agent for AVM, AV fistulas and tumors. Turk Neurosurg 24:565–570
Bank WO, Stemer AB, Armonda RA, Bell RS (2014) Intermittent balloon occlusion to favor nidal penetration during embolization of arteriovenous malformations: a technique modification. J Neurointerv Surg 6(4):e28
Peschillo S, Caporlingua A, Colonnese C, Guidetti G (2014) Brain AVMs: an endovascular, surgical, and radiosurgical update. ScientificWorldJournal 2014:834931
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Xu, H., Wang, L., Guan, S. et al. Embolization of brain arteriovenous malformations with the diluted Onyx technique: initial experience. Neuroradiology 61, 471–478 (2019). https://doi.org/10.1007/s00234-019-02176-2
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DOI: https://doi.org/10.1007/s00234-019-02176-2