Technical noteOnyx embolization using dual-lumen balloon catheter: Initial experience and technical note
Introduction
As an embolization agent for the management of vascular malformations, Onyx has been well established for the treatment of brain arteriovenous malformations (AVMs), dural AVMs, and facial and vertebral vascular malformations [1], [2], [3]. The recent introduction of dimethyl-sulfoxide (DMSO)-compatible double-lumen balloon catheters has enhanced the ability to overcome some of the shortcomings associated with Onyx embolization. This report describes our initial experience as well as the embolization techniques and advantages of using DMSO-compatible double-lumen balloon catheters.
Section snippets
Methods and technique
Between December 2011 to March 2013, two types of DMSO-compatible dual-lumen balloon catheters – the Scepter C (MicroVention Terumo, Tustin, CA, USA) and the Ascent (Codman Neurovascular, Raynham, MA, USA) – were used to treat craniofacial vascular malformations such as dural arteriovenous fistulas, brain AVMs with dural feeders, and mandibular, facial, lingual, vertebral and paravertebral AVMs. In 22 patients aged 1.5–70 years, 30 attempts were made to use dual-lumen balloon catheters and were
Injection of Onyx
Prior to Onyx injection, 1 mL of lidocaine (20 mg/mL) was infused, followed by 3–6 ml of a saline flush to ensure that no residual contrast/lidocaine remained in the catheter. The dead space in the microballoon catheter was filled with DMSO (0.45 mL). The DMSO was then removed from the hub of the microcatheter and replaced by Onyx, and the DMSO in the catheter was injected slowly over 1 minute. Once Onyx starts to fill the malformation, the injection rate is determined by how rapidly the Onyx
Results
In the present series, all of the catheterizations attempted were in either dural or extracranial vessels. In all, 30 attempts were made using the dual-lumen balloon catheter, which was successfully placed at the desired location in 28 cases. An Ascent balloon catheter was used twice and the Scepter C balloon catheter in all the others. Four patients required more than one embolization using the balloon catheter (Table 1).
Onyx injection time in our series ranged from 4 to 78 minutes. The
Discussion
Endovascular embolization is currently the primary modality used in the treatment of brain, dural, craniofacial and vertebral AVMs. Onyx embolization is widely used and its safety profile is acceptable [4]: it appears to be equivalent in safety and efficacy to the traditionally used liquid embolic glue N-butyl-2-cyanoacrylate (NBCA) [5]. The physical properties of Onyx make it ideal for embolization of most AVMs. Unlike NBCA, it can be injected in a controlled fashion, thereby allowing Onyx to
Conclusion
Dual-lumen balloon catheter Onyx embolization is a safe and effective technique that is currently an important tool for circumventing some of the shortcomings associated with Onyx embolization. The balloon catheter has good navigability and requires no Onyx plug formation. The balloon is stable and can tolerate the pressure buildup well resulting in improved penetrability of Onyx. Microcatheter removal after embolization is easy, thereby reducing the risk of a trapped catheter. With a greater
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
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2020, Journal of Clinical NeuroscienceCitation Excerpt :Whether this result is due to better technical performance remains to be proven definitively, but the ability of the Scepter catheter to arrest flow with relative ease by inflating the balloon, as opposed to the forming of a proximal plug, may allow for increased Onyx injection and thus improved embolization. Any use of a balloon within a vessel comes with a host of complications, including catheter rupture, over-inflation of the Scepter balloon, and catheter retention [6,9,18]. Of these, vessel rupture and ensuing hemorrhage is a significant concern.
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2020, World NeurosurgeryCitation Excerpt :If needed, the detachable tip reduces the risk of pulling or tearing the vessel if proximal occlusion has entrapped the microcatheter tip. Balloon-assisted embolization techniques have also evolved favorable, largely due to the introduction of dual-lumen balloon catheters such as Sceptor (MicroVention, Inc., Aliso Viejo, California, USA).11 Thus, balloon-assisted protection from proximal reflux has become more reliable and feasible.
Embolic Agents and Microcatheters for Endovascular Treatment of Cerebral Arteriovenous Malformations
2020, World NeurosurgeryCitation Excerpt :Another potential concern for this technique is that increased arterial flow distal to the site of balloon occlusion could cause embolic agent to traverse arterial-arterial or arterial-venous anastomoses, which could lead to embolic or hemorrhagic stroke.22 Several authors report that narrow target vessels are inaccessible with these catheters, which could be a point of improvement for future models.24,27 Endovascular embolization of brain AVMs has traditionally been an adjuvant treatment, but with improvements in the efficacy and safety of endovascular devices, embolization has emerged over the last decade to become a standard element in the multimodal treatment of AVMs.
The Procedure-Related Complications of Transarterial Onyx Embolization of Dural Arteriovenous Fistula Using Transvenous Balloon Protection
2018, World NeurosurgeryCitation Excerpt :The reasons may be that the fistula network had been partially blocked, so the embolic material couldn't penetrate through the network to adjacent feeding arteries enough to total occlusion even with the help of balloon. For such cases, a transarterial double lumen balloon may be helpful, with some reports showing that the double lumen balloon catheter could form a plug in small feeding artery and provide enough encouragement to achieve good penetration of Onyx throughout the vascular network of the fistula.11-15 The combination of the transarterial and transvenous balloon–assisted technique showed inspiring results.13,16
Transvenous onyx embolization for dural arteriovenous fistula with concomitant transvenous balloon protection of the venous sinus
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