Elsevier

Journal of Neuroradiology

Volume 40, Issue 4, October 2013, Pages 294-302
Journal of Neuroradiology

Technical note
Onyx embolization using dual-lumen balloon catheter: Initial experience and technical note

https://doi.org/10.1016/j.neurad.2013.08.001Get rights and content

Summary

Introduction

Onyx as an embolization agent for the management of vascular malformation is well established. We report our initial experience with dimethyl-sulphoxide (DMSO) compatible double lumen balloon catheters used for Onyx embolization.

Methods and technique

Between December 2011 and March 2013, we treated 22 patients aged between 1.5 to 70 years with two types of DMSO compatible dual-lumen balloon catheters (Scepter C and Ascent) to treat dural arteriovenous fistulas, brain arteriovenous malformation (AVM) with dural feeders, mandibular, facial, lingual, vertebral and paravertebral AVMs. The catheter has good navigability, compliant balloon on inflation formed a “plug” that has more resistance than Onyx plug enhancing better penetration. During injection, the balloon remained stable without spontaneous deflation or rupture and withstood the pressure build-up well. The retrieval of the catheter in most cases took less than a minute (19/28) while in five, it was less than five minutes and in the remaining four, it was longer that includes a trapped catheter on prolonged attempted retrieval resulted in an epidural hematoma, requiring emergent surgical evacuation. The fluoroscopy time is reduced, as we do not form a proximal onyx plug, the injection time is shorter along with easy and instantaneous removal of the catheter after balloon deflation in most cases.

Conclusion

Dual-lumen balloon catheter Onyx embolization is a safe and effective technique. Currently, an important tool to circumvent some of the shortcomings associated with Onyx embolization. The catheter has good navigability, the balloon has stability, tolerance, enhances penetrability. It is easy to retrieve the microcatheter. With the experience gained, and with more compliant balloon catheters available, this technique can be applied to cerebral vessels in near future.

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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