1
|
Sakakura Y, Masuo O, Fujimoto T, Terada T, Kono K. Pioneering artificial intelligence-based real time assistance for intracranial liquid embolization in humans: an initial experience. J Neurointerv Surg 2024:jnis-2024-022001. [PMID: 38937087 DOI: 10.1136/jnis-2024-022001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Liquid embolization in neuroendovascular procedures carries the risk of embolizing an inappropriate vessel. Operators must pay close attention to multiple vessels during the procedure to avoid ischemic complications. We report our experience with real time artificial intelligence (AI) assisted liquid embolization and evaluate its performance. METHODS An AI-based system (Neuro-Vascular Assist, iMed technologies, Tokyo, Japan) was used in eight endovascular liquid embolization procedures in two institutions. The software automatically detects liquid embolic agent on biplane fluoroscopy images in real time and notifies operators when the agent reaches a predefined area. Safety, efficacy, and accuracy of the notifications were evaluated using recorded videos. RESULTS Onyx or n-butyl-2-cyanoacrylate (NBCA) was used in the treatment of arteriovenous malformation, dural arteriovenous fistula, meningioma, and chronic subdural hematoma. The mean number of true positive and false negative notifications per case was 31.8 and 2.8, respectively. No false positive notifications occurred. The precision and recall of the notifications were 100% and 92.0%, respectively. In 28.3% of the true positive notifications, the operator immediately paused agent injection after receiving the notification, which demonstrates the potential effectiveness of the AI-based system. No adverse events were associated with the notifications. CONCLUSIONS To the best of our knowledge, this is the first report of real time AI assistance with liquid embolization procedures in humans. The system demonstrated high notification accuracy, safety, and potential clinical usefulness in liquid embolization procedures. Further research is warranted to validate its impact on clinical outcomes. AI-based real time surgical support has the potential to advance neuroendovascular treatment.
Collapse
Affiliation(s)
- Yuya Sakakura
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-ku, Japan
| | - Osamu Masuo
- Department of Neuroendovascular Surgery, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Takeshi Fujimoto
- Department of Neurosurgery, Numata Neurosurgery & Cardiovascular Hospital, Numata, Gunma, Japan
| | - Tomoaki Terada
- Department of Neurosurgery, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Kenichi Kono
- Department of Neurosurgery, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
- iMed Technologies, Bunkyo-ku, Tokyo, Japan
| |
Collapse
|
2
|
Alexandre AM, Scarcia L, Clarençon F, Camilli A, Bartolo A, Incandela F, Mele DA, Rigante M, Natola M, Valente I, D'Argento F, Galli J, Tshomba Y, Pedicelli A. Preoperative Direct Puncture Embolization Using a Nonadhesive Ethylene Vinyl Alcohol (EVOH) Liquid Embolic Agent for Head and Neck Paragangliomas. Clin Neuroradiol 2024; 34:307-314. [PMID: 38066106 DOI: 10.1007/s00062-023-01364-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/07/2023] [Indexed: 05/29/2024]
Abstract
PURPOSE This retrospective study aimed to assess the safety and technical efficacy of preoperative direct puncture embolization using a nonadhesive ethylene vinyl alcohol (EVOH) copolymer-based liquid embolic agent (LEA) combined with balloon occlusion at the origin of the external carotid artery for head and neck paragangliomas (HNP). METHODS We conducted a review of all consecutive cases of HNPs treated with direct puncture embolization using EVOH-based LEAs between 2017 and 2022 in 2 tertiary high-volume hospitals. RESULTS A total of 25 cases of HNPs in 24 patients underwent direct puncture embolization (12 males, 12 females, mean age 50.9 ± 15.6 years). The average lesion volume was 299.95 mm3. The mean procedure time was 139.11 min, and the mean volume of EVOHs used per case was 19.38 mL. Successful complete devascularization was achieved in all cases, with a homogeneous and deep penetration of the embolic agent into the tumor vessel bed regardless of the LEA type. CONCLUSION Preoperative embolization of HNPs using a direct puncture technique and EVOHs is a safe, efficient, and feasible treatment option with a low risk of complications. This procedure facilitates surgery by transforming tumors into avascular masses that are well-delineated against the surrounding normal tissue.
Collapse
Affiliation(s)
- Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy.
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Sorbonne University, APHP, 47, Bd de l'Hôpital, 75013, Paris, France
- Sorbonne University, Paris, France
| | - Arianna Camilli
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
| | - Andrea Bartolo
- Diagnostic and Therapeutic Neuroradiology Unit, IRCCS INM Neuromed, 86077, Isernia, Italy
| | - Francesca Incandela
- UOC Neuroradiologia diagnostica ed interventistica, Arnas Civico Palermo, Italy
| | - Dario Antonio Mele
- Unit of Otorhinolaryngology, Fondazione Policlinico Universitario A.Gemelli IRCCS, 00168, Rome, Italy
| | - Mario Rigante
- Unit of Otorhinolaryngology, Fondazione Policlinico Universitario A.Gemelli IRCCS, 00168, Rome, Italy
| | - Marco Natola
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Francesco D'Argento
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Jacopo Galli
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
- Unit of Otorhinolaryngology, Fondazione Policlinico Universitario A.Gemelli IRCCS, 00168, Rome, Italy
| | - Yamume Tshomba
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, 00168, Roma, Largo Agostino Gemelli, Italy
| |
Collapse
|
3
|
Rajab IM, Adas A, Shubietah AR, Khader MI. Successful embolization of an anterior chest wall arteriovenous malformation using combined transfemoral and transradial approaches with onyx. Radiol Case Rep 2024; 19:2151-2155. [PMID: 38515770 PMCID: PMC10950610 DOI: 10.1016/j.radcr.2024.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 03/23/2024] Open
Abstract
We present a case of successful embolization of an anterior chest wall arteriovenous malformation (AVM) in a 24-year-old male patient. This report aims to highlight the efficacy and safety of using the liquid embolic agent (onyx) as well as the combined approaches (trans-femoral and trans-radial) in managing rare complex chest wall AVMs.
Collapse
Affiliation(s)
- Islam M. Rajab
- Internal Medicine Department, Al-Israa Speciality Hospital, Tulkarm, Palestine
- Department of Radiology, An-Najah National University Hospital, Nablus, Palestine
| | - Abdelkarim Adas
- Thoracic Surgery, An-Najah National University Hospital, Nablus, Palestine
| | - Abdalhakim R.M. Shubietah
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
- Internal Medicine Department, An-Najah National University Hospital, Nablus, Palestine
| | - Mohammed I. Khader
- Interventional Radiology, An-Najah National University Hospital, Nablus, Palestine
| |
Collapse
|
4
|
Perri P, Sena G, Piro P, De Bartolo T, Galassi S, Costa D, Serra R. Onyx TMGel or Coil versus Hydrogel as Embolic Agents in Endovascular Applications: Review of the Literature and Case Series. Gels 2024; 10:312. [PMID: 38786229 PMCID: PMC11120993 DOI: 10.3390/gels10050312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
This review focuses on the use of conventional gel or coil and "new" generation hydrogel used as an embolic agent in endovascular applications. In general, embolic agents have deep or multidistrict vascular penetration properties as they ensure complete occlusion of vessels by exploiting the patient's coagulation system, which recognises them as substances foreign to the body, thus triggering the coagulation cascade. This is why they are widely used in the treatment of endovascular corrections (EV repair), arteriovenous malformations (AVM), endoleaks (E), visceral aneurysms or pseudo-aneurysms, and embolisation of pre-surgical or post-surgical (iatrogenic) lesions. Conventional gels such as Onyx or coils are now commercially available, both of which are frequently used in endovascular interventional procedures, as they are minimally invasive and have numerous advantages over conventional open repair (OR) surgery. Recently, these agents have been modified and optimised to develop new embolic substances in the form of hydrogels based on alginate, chitosan, fibroin and other polymers to ensure embolisation through phase transition phenomena. The main aim of this work was to expand on the data already known in the literature concerning the application of these devices in the endovascular field, focusing on the advantages, disadvantages and safety profiles of conventional and innovative embolic agents and also through some clinical cases reported. The clinical case series concerns the correction and exclusion of endoleak type I or type II appeared after an endovascular procedure of exclusion of aneurysmal abdominal aortic (EVAR) with a coil (coil penumbra released by a LANTERN microcatheter), the exclusion of renal arterial malformation (MAV) with a coil (penumbra coil released by a LANTERN microcatheter) and the correction of endoleak through the application of Onyx 18 in the arteries where sealing by the endoprosthesis was not guaranteed.
Collapse
Affiliation(s)
- Paolo Perri
- Department of Vascular and Endovascular Surgery, Annunziata Hospital, 1 Via Migliori, 87100 Cosenza, Italy; (P.P.); (P.P.)
| | - Giuseppe Sena
- Department of Vascular Surgery, “Pugliese-Ciaccio” Hospital, 88100 Catanzaro, Italy;
| | - Paolo Piro
- Department of Vascular and Endovascular Surgery, Annunziata Hospital, 1 Via Migliori, 87100 Cosenza, Italy; (P.P.); (P.P.)
| | - Tommaso De Bartolo
- Departement of Interventional Radiology, Annunziata Hospital, 1 Via Migliori, 87100 Cosenza, Italy; (T.D.B.); (S.G.)
| | - Stefania Galassi
- Departement of Interventional Radiology, Annunziata Hospital, 1 Via Migliori, 87100 Cosenza, Italy; (T.D.B.); (S.G.)
| | - Davide Costa
- Interuniversity Center of Phlebolymphology (CIFL), Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy;
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| |
Collapse
|
5
|
Samaniego EA, Dabus G, Meyers PM, Kan PT, Frösen J, Lanzino G, Welch BG, Volovici V, Gonzalez F, Fifi J, Charbel FT, Hoh BL, Khalessi A, Marks MP, Berenstein A, Pereira VM, Bain M, Colby GP, Narayanan S, Tateshima S, Siddiqui AH, Wakhloo AK, Arthur AS, Lawton MT. Most Promising Approaches to Improve Brain AVM Management: ARISE I Consensus Recommendations. Stroke 2024; 55:1449-1463. [PMID: 38648282 DOI: 10.1161/strokeaha.124.046725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/01/2024] [Indexed: 04/25/2024]
Abstract
Brain arteriovenous malformations (bAVMs) are complex, and rare arteriovenous shunts that present with a wide range of signs and symptoms, with intracerebral hemorrhage being the most severe. Despite prior societal position statements, there is no consensus on the management of these lesions. ARISE (Aneurysm/bAVM/cSDH Roundtable Discussion With Industry and Stroke Experts) was convened to discuss evidence-based approaches and enhance our understanding of these complex lesions. ARISE identified the need to develop scales to predict the risk of rupture of bAVMs, and the use of common data elements to perform prospective registries and clinical studies. Additionally, the group underscored the need for comprehensive patient management with specialized centers with expertise in cranial and spinal microsurgery, neurological endovascular surgery, and stereotactic radiosurgery. The collection of prospective multicenter data and gross specimens was deemed essential for improving bAVM characterization, genetic evaluation, and phenotyping. Finally, bAVMs should be managed within a multidisciplinary framework, with clinical studies and research conducted collaboratively across multiple centers, harnessing the collective expertise and centralization of resources.
Collapse
Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa (E.A.S.)
| | - Guilherme Dabus
- Department of Neurosurgery, Baptist Health, Miami, FL (G.D.)
| | - Philip M Meyers
- Department of Radiology and Neurological Surgery, Columbia University, New York (P.M.M.)
| | - Peter T Kan
- Department of Neurological Surgery, University of Texas Medical Branch Galveston (P.T.K.)
| | - Juhana Frösen
- Department of Rehabilitation, Tampere University Hospital, Finland (J.F.)
| | | | - Babu G Welch
- Departments of Neurological Surgery and Radiology; The University of Texas Southwestern, Dallas (B.G.W.)
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands (V.V.)
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD (F.G.)
| | - Johana Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago (F.T.C.)
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville (B.L.H.)
| | | | - Michael P Marks
- Interventional Neuroradiology Division, Stanford University Medical Center, Palo Alto, CA (M.P.M.)
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Victor M Pereira
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Canada (V.M.P.)
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, OH (M.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles (G.P.C.)
| | - Sandra Narayanan
- Neurointerventional Program and Comprehensive Stroke Program, Pacific Neuroscience Institute, Santa Monica, CA (S.N.)
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles (S.T.)
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York (A.H.S.)
| | - Ajay K Wakhloo
- Department of Radiology, Tufts University School of Medicine, Boston, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis (A.S.A.)
| | - Michael T Lawton
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
| |
Collapse
|
6
|
Guerra X, Sapoval M, Querub C, Al Ahmar M, Di Gaeta A, Dean C, Pellerin O, Boeken T. Repeat Prostatic Artery Embolization with the Addition of a Liquid Embolic Agent: Short-term Results. Acad Radiol 2024; 31:1959-1967. [PMID: 37996363 DOI: 10.1016/j.acra.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 11/25/2023]
Abstract
RATIONALE AND OBJECTIVES The long-term effectiveness of prostatic artery embolization (PAE) can be hampered by the recanalization of the previously embolized prostatic arteries (PA). The use of a liquid embolic agent (LEA) could limit this risk. The purpose of this study was to assess the safety and efficacy of repeat PAE (rePAE) using a LEA (Squid Peri) coupled with microspheres in patients experiencing recurring symptoms after initial embolization. MATERIALS AND METHODS This retrospective single-center study included all consecutive patients who underwent rePAE using Squid Peri coupled with microspheres. Angiographic patterns of prostatic revascularization were identified. Outcomes were assessed at the 3-month follow-up using the International Prostate Symptom Score (IPSS) and the Quality of Life (QoL) score. The primary endpoint was clinical success defined as an IPSS < 18 with > 25% decrease and a QoL score ≤ 3 with ≥ 1 point decrease. Safety was assessed by using the modified Clavien-Dindo classification. RESULTS 30 consecutive men (mean age: 67.1 ± 9.5 years) were included. Recanalization of the previously embolized PA was found in 83.3% of patients. Technical success was 93.3%. Median follow-up was 4.9 months [IQR: 3.9 - 9.8]. Clinical success rate was 76.7%, with a mean decrease in IPSS of -9.3 ± 7.3 (p < 0.001) and a median decrease in QoL of -2 [IQR: - 4 - - 1] (p < 0.001). One patient presented with an acute urinary retention requiring readmission (grade IIIa complication). CONCLUSION Repeat PAE using Squid Peri coupled with microspheres is safe and effective for patients with recurring symptoms after initial embolization.
Collapse
Affiliation(s)
- Xavier Guerra
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France; Université Paris Cité, Faculté de Santé, Paris, France.
| | - Marc Sapoval
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France; Université Paris Cité, Faculté de Santé, Paris, France; PARCC U 970, INSERM, Paris, France
| | - Charles Querub
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France; Université Paris Cité, Faculté de Santé, Paris, France
| | - Marc Al Ahmar
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France
| | - Alessandro Di Gaeta
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France
| | - Carole Dean
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France
| | - Olivier Pellerin
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France; Université Paris Cité, Faculté de Santé, Paris, France; PARCC U 970, INSERM, Paris, France
| | - Tom Boeken
- Vascular and oncological interventional radiology department, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, 20 Rue Leblanc, 75015, Paris, France; Université Paris Cité, Faculté de Santé, Paris, France; HeKA team, INRIA, Paris, France
| |
Collapse
|
7
|
Golub D, Lynch DG, Mehta SH, Donaldson H, Shah KA, White TG, Quach ET, Papadimitriou K, Kuffer AF, Woo HH, Link TW, Patsalides A, Dehdashti AR. The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series. Neurosurg Rev 2024; 47:189. [PMID: 38658425 DOI: 10.1007/s10143-024-02407-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/26/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited. METHODS Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis and supported by comprehensive angiographic and intraoperative images. RESULTS One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk for endovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation. CONCLUSIONS This illustrative case series highlights the technical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.
Collapse
Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA.
| | - Daniel G Lynch
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Shyle H Mehta
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Hayley Donaldson
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kevin A Shah
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Eric T Quach
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | | | | | - Henry H Woo
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Thomas W Link
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| |
Collapse
|
8
|
Salem MM, Kelmer P, Sioutas GS, Ostmeier S, Hoang A, Cortez G, El Naamani K, Abbas R, Hanel R, Tanweer O, Srinivasan VM, Jabbour P, Kan P, Jankowitz BT, Heit JJ, Burkhardt JK. Multicenter US clinical experience with the Scepter Mini balloon catheter. Interv Neuroradiol 2024:15910199241246135. [PMID: 38613371 DOI: 10.1177/15910199241246135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
INTRODUCTION Distal navigability and imprecise delivery of embolic agents are two limitations encountered during liquid embolization of cerebrospinal lesions. The dual-lumen Scepter Mini balloon (SMB) microcatheter was introduced to overcome these conventional microcatheters' limitations with few small single-center reports suggesting favorable results. METHODS A series of consecutive patients undergoing SMB-assisted endovascular embolization were extracted from prospectively maintained registries in seven North-American centers (November 2019 to September 2022). RESULTS Fifty-four patients undergoing 55 embolization procedures utilizing SMB were included (median age 58.5; 48.1% females). Cranial dural arteriovenous fistula embolization was the most common indication (54.5%) followed by cranial arteriovenous malformation (27.3%). Staged/pre-operative embolization was done in 36.4% of cases; and 83.6% of procedures using Onyx-18. Most procedures utilized a transarterial approach (89.1%), and SMB-induced arterial-flow arrest concurrently with transvenous embolization was used in 10.9% of procedures. Femoral access/triaxial setups were utilized in the majority of procedures (65.5% and 60%, respectively). The median vessel diameter where the balloon was inflated of 1.8 mm, with a median of 1.5 cc of injected embolic material per procedure. Technical failures occurred in 5.5% of cases requiring aborting/replacement with other devices without clinical sequelae in any of the patients, with SMB-related procedural complications of 3.6% without clinical sequelae. Radiographic imaging follow-up was available in 76.9% of the patients (median follow-up 3.8 months), with complete occlusion (100%) or >50% occlusion in 92.5% of the cases, and unplanned retreatments in 1.8%. CONCLUSION The SMB microcatheter is a useful new adjunctive device for balloon-assisted embolization of cerebrospinal lesions with a high technical success rate, favorable outcomes, and a reasonable safety profile.
Collapse
Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Paz Kelmer
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Sophie Ostmeier
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
| | - Alex Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Gustavo Cortez
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Ricardo Hanel
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch Galveston, Galveston, TX, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Jeremy J Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| |
Collapse
|
9
|
Chen X, Ge L, Wan H, Jiang Y, Huang L, Pan T, Lu G, Zhang X. Measurement of sinus wall thickness and wall enhancement index in dural arteriovenous fistulae by magnetic resonance vessel wall imaging. Magn Reson Imaging 2024:S0730-725X(24)00108-5. [PMID: 38579973 DOI: 10.1016/j.mri.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Dural sinus wall thickness and wall enhancement index (WEI) of dural arteriovenous fistulae (DAVFs) have not been well characterized. This study aimed to measure the sinus wall thickness and WEI by using magnetic resonance vessel wall imaging (MR-VWI). METHODS A total 27 DAVF patients and 30 normal healthy individuals were enrolled in this study. All participants were scanned by a 3 T MR scanner with the black blood sequence. The wall thickness and the WEI of the great cerebral vein, the intracranial main dural sinuses with DAVFs, and the contralateral sinuses were measured by two independent neuroradiologists. RESULTS The DAVF-affected sinuses had significantly thicker walls (2.277 ± 0.311 mm vs. 1.446 ± 0.188 mm, P < 0.001) and significantly higher WEI (2.253 ± 0.462 vs. 1.173 ± 0.418, P < 0.001) compared to the contralateral ones. They also had significantly thicker walls (2.277 ± 0.311 mm vs. 1.643 ± 0.173 mm, P < 0.001) and significantly higher WEI (2.253 ± 0.462 vs. 1.124 ± 0.254, P < 0.001) compared to the normal controls. Neither the sinus wall thickness (r = -0.317, P = 0.107) nor the WEI (r = 0.019, P = 0.923) was significantly correlated with the Cognard types in DAVF patients. The WEI of the DAVF draining vein was significantly higher compared to the static venous wall (1.972 ± 0.629 vs. 0.532 ± 0.243, P < 0.001). CONCLUSION T1-CUBE MRI is useful in measuring sinus all thickness and WEI of DAVFs, providing a new method for diagnosing this disease.
Collapse
Affiliation(s)
- Xi Chen
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Liang Ge
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hailin Wan
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yeqing Jiang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Huang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ting Pan
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Lu
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaolong Zhang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China.
| |
Collapse
|
10
|
Zhao K, Varghese P J G, Chen P, Hu J. Developing a transcatheter injectable nanoclay- alginate gel for minimally invasive procedures. J Mech Behav Biomed Mater 2024; 152:106448. [PMID: 38335649 PMCID: PMC10923083 DOI: 10.1016/j.jmbbm.2024.106448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
Shear-thinning materials have held considerable promise as embolic agents due to their capability of transition between solid and liquid state. In this study, a laponite nanoclay (NC)/alginate gel embolic agent was developed, characterized, and studied for transcatheter based minimally invasive procedures. Both NC and alginate are biocompatible and FDA-approved. Due to electrostatic interactions, the NC/alginate gels exhibit shear-thinning properties that are desirable for transcatheter delivery. The unique shear-thinning nature of the NC/alginate gel allows it to function as a fluid-like substance during transcatheter delivery and as a solid-like embolic agent once deployed. To ensure optimal performance and safety in clinical applications, the rheological characteristics were thoroughly investigated to optimize the mechanical properties of the NC/alginate gel, including storage modulus, yield stress/strain, and thixotropy. To improve physicians' experience and enhance the predictability of gel delivery, a combination of experimental and theoretical approaches was used to assess the injection force required for successful delivery of the gel through clinically employed catheters. Overall, NC/alginate gel exhibited excellent stability and tunable injectability by optimizing the composition of each component. These findings highlight the gel's potential as a robust embolic agent for a wide range of minimally invasive procedures.
Collapse
Affiliation(s)
- Keren Zhao
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA
| | - George Varghese P J
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA
| | - Peng Chen
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA
| | - Jingjie Hu
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA.
| |
Collapse
|
11
|
Ma Y, Li Z, Feng Y, Zhang T, Chen X, Zhao W. Endovascular treatment of intracranial dural arteriovenous fistulas with Onyx: A consecutive series of 62 patients from a single-center. Neuroradiol J 2024:19714009241242586. [PMID: 38557275 DOI: 10.1177/19714009241242586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE Intracranial intracranial dural arteriovenous fistulas (DAVFs) are mainly treated with an endovascular approach and various embolic agents. The aim of this study was to investigate the efficacy and safety of Onyx embolization in the treatment of DAVFs and characterize the factors as sociated with complete obliteration. METHODS This retrospective study was based on 62 patients with DAVFs who underwent endovascular treatment with Onyx alone or in combination with coils at our institution. Clinical and imaging data were collected and analyzed. RESULTS A total of 62 patients with 64 DAVFs were treated with endovascular embolization. The most common primary symptom was ophthalmological signs with a rate of 37.1%. Cognard type III was the most commonly seen subtype (32.8%). The immediate complete occlusion and follow-up rate was 92.2% and 93.5%, respectively. Transvenous balloon-assisted sinus protection was used in 12 patients (18.8%). The pressure cooker technique was used in eight patients (12.5%). Complications were seen in five patients including intracerebral hemorrhage (n = 2), venous thrombotic events (n = 2), and glued microcatheter (n = 1). CONCLUSIONS Endovascular Onyx alone or in combination with coils embolization is a safe and effective therapy for DAVFs. Favorable angiographic and clinical outcomes can be achieved using different endovascular approaches. Transvenous balloon-assisted sinus protection and the pressure cooker technique may help achieve complete occlusion of DAVFs.
Collapse
Affiliation(s)
- Yihui Ma
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, China
| | - Zejin Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, China
| | - Yu Feng
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, China
| | - Tingbao Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, China
| | - Xinjun Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, China
| | - Wenyuan Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, China
| |
Collapse
|
12
|
Elmore LR, Esper C, Gritsiuta AI, Lara-Gutierrez J, Downs P, Henwood J. Surgical Treatment of Spontaneous Superficial Temporal Artery Arteriovenous Malformation: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e942839. [PMID: 38555492 PMCID: PMC10993735 DOI: 10.12659/ajcr.942839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/12/2024] [Accepted: 02/06/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND An arteriovenous malformation (AVM) is an abnormal connection between an artery and a vein, bypassing the capillary network. An AVM of the superficial temporal artery (STA) can occur after trauma, iatrogenic injury, infection, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few reported cases. Symptoms include local pain, headache, tinnitus, or paresthesia, in addition to a palpable mass associated with thrill on palpation. Options for diagnosis include intra-arterial angiography, doppler ultrasound, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Current management options include surgical excision, ligation, and embolization; however, it is unknown which treatment is superior in terms of recurrence and which carries a lower risk of complications. CASE REPORT We present a case of a spontaneous STA AVM in a 76-year-old woman with past medical history significant for seasonal allergies and hyperlipidemia, who presented with pulsatile tinnitus and a palpable, tender mass located to the left temporal area. The mass had been present for several years, with gradual increase in size two to three years prior to presentation. She denied any history of trauma or procedure prior to presentation of the pulsatile mass. She underwent open excision with complete resolution of symptoms and no recurrence at 11-month follow-up. CONCLUSIONS AVM of the STA is a condition that can occur secondary to trauma, infection, iatrogenic injury, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few cases documented in the literature. Surgical treatment remains the standard of management, with options including surgical excision, ligation, or embolization.
Collapse
|
13
|
Geng Y, Zou H, Li Z, Wu H. Recent advances in nanomaterial-driven strategies for diagnosis and therapy of vascular anomalies. J Nanobiotechnology 2024; 22:120. [PMID: 38500178 PMCID: PMC10949774 DOI: 10.1186/s12951-024-02370-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/23/2024] [Indexed: 03/20/2024] Open
Abstract
Nanotechnology has demonstrated immense potential in various fields, especially in biomedical field. Among these domains, the development of nanotechnology for diagnosing and treating vascular anomalies has garnered significant attention. Vascular anomalies refer to structural and functional anomalies within the vascular system, which can result in conditions such as vascular malformations and tumors. These anomalies can significantly impact the quality of life of patients and pose significant health concerns. Nanoscale contrast agents have been developed for targeted imaging of blood vessels, enabling more precise identification and characterization of vascular anomalies. These contrast agents can be designed to bind specifically to abnormal blood vessels, providing healthcare professionals with a clearer view of the affected areas. More importantly, nanotechnology also offers promising solutions for targeted therapeutic interventions. Nanoparticles can be engineered to deliver drugs directly to the site of vascular anomalies, maximizing therapeutic effects while minimizing side effects on healthy tissues. Meanwhile, by incorporating functional components into nanoparticles, such as photosensitizers, nanotechnology enables innovative treatment modalities such as photothermal therapy and photodynamic therapy. This review focuses on the applications and potential of nanotechnology in the imaging and therapy of vascular anomalies, as well as discusses the present challenges and future directions.
Collapse
Affiliation(s)
- Yiming Geng
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, China
| | - Huwei Zou
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, China
| | - Zhaowei Li
- School of Radiology, Shandong First Medical University and Shandong Academy of Medical Sciences, 619 Changcheng Road, Tai'an, 271000, China.
| | - Haiwei Wu
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, China.
| |
Collapse
|
14
|
Robledo A, Frank TS, Karas PJ, Shaltoni H, O'Leary S, Darling R, Kan P. Stereotactic-guided direct orbital puncture for treatment of orbital arteriovenous fistula. J Neurointerv Surg 2024; 16:429. [PMID: 37142395 DOI: 10.1136/jnis-2023-020145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023]
Abstract
The patient presented with left-sided chemosis, exophthalmos, and progressive visual loss. Cerebral angiography ed a left orbital arteriovenous malformation and an associated hematoma, with the point of fistulation between the left ophthalmic artery and the anterior section of the inferior ophthalmic vein, with retrograde flow through the superior ophthalmic vein. Transvenous embolization through the anterior facial and angular veins was unsuccessful, with residual shunting. Stereotactic-guided direct venous puncture and Onyx embolization was subsequently performed in the hybrid operating room (OR) to cure the fistula. A subciliary incision allowed for retraction of the orbital contents, creating an optimal trajectory. An endonasal endoscopic approach was performed after the embolization to decompress the orbit. This procedure is shown in video 11-11 neurintsurg;16/4/429/V1F1V1Video 1 .
Collapse
Affiliation(s)
- Ariadna Robledo
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Thomas S Frank
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Patrick J Karas
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Hashem Shaltoni
- Neurology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Sean O'Leary
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Robert Darling
- Otolaryngology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| |
Collapse
|
15
|
Withayasuk P, Wichianrat R, Sangpetngam B, Aurboonyawat T, Chankaew E, Homsud S, Churojana A. Vertebro-Vertebral Arteriovenous Fistulae: A Case Series of Endovascular Management at a Single Center. Diagnostics (Basel) 2024; 14:414. [PMID: 38396452 PMCID: PMC10887677 DOI: 10.3390/diagnostics14040414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVE Vertebro-vertebral arteriovenous fistulae (VVFs) are a rare disorder characterized by a direct shunt between the extracranial vertebral artery and the veins of the vertebral venous plexus. This study aims to comprehensively review the characteristics and outcomes of endovascular treatments for VVFs at our center. METHODS A retrospective review was conducted on 14 patients diagnosed with a VVF who underwent endovascular treatment at Siriraj Hospital from January 2000 to January 2023. The study assessed patient demographics, presentation, fistula location, treatment strategies, endovascular techniques employed, and treatment outcomes. RESULTS Among the 14 patients, 11 (78.6%) were female, with an age range from 25 to 79 years (median: 50 years). Spontaneous VVFs were observed in 64.3% of the cases, including three associated with neurofibromatosis type 1 (NF-1). Iatrogenic injury accounted for two cases, and three patients had VVFs resulting from traffic accidents. A pulsatile neck mass and tinnitus, with or without neurological deficits, were common presenting symptoms. Active bleeding was observed in three cases with vascular injury, while unilateral proptosis, congestive heart failure, and incidental findings each presented in one patient. All the VVFs were successfully obliterated without major treatment complications. Parent vessel sacrifice was performed in 85.7% of the cases, while vertebral artery preservation was achieved in the remaining two patients. Embolic materials included detachable balloons, detachable coils, and n-butyl cyanoacrylate (NBCA) glue. All the presenting symptoms showed improvement, and no morbidity or mortality was observed. CONCLUSIONS Endovascular embolization is a feasible and effective approach for achieving complete VVF obliteration with safety. Parent artery sacrifice should not be reluctantly performed, particularly when adequate collateral circulation is demonstrated.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Anchalee Churojana
- Siriraj Center of Interventional Radiology, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (P.W.); (R.W.); (B.S.); (T.A.); (E.C.); (S.H.)
| |
Collapse
|
16
|
Alonso-Burgos A, Díaz-Lorenzo I, Muñoz-Saá L, Gallardo G, Castellanos T, Cardenas R, Chiva de Agustín L. Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach. CVIR Endovasc 2024; 7:17. [PMID: 38349501 PMCID: PMC10864234 DOI: 10.1186/s42155-024-00429-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.
Collapse
Affiliation(s)
- Alberto Alonso-Burgos
- Radiology Department, Vascular Surgery and Interventional Radiology Unit, University Clinic of Navarra, Clínica Universidad de Navarra, Marquesado de Santa Marta 1, 28027, Madrid, Spain.
| | - Ignacio Díaz-Lorenzo
- Radiology Department, Interventional Radiology Unit, University Hospital La Princesa, Madrid, Spain
| | - Laura Muñoz-Saá
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
| | | | | | - Regina Cardenas
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
| | | |
Collapse
|
17
|
Zhang G, Zhang W, Chang H, Shen Y, Ma C, Mao L, Li Z, Lu H. Endovascular treatment strategy and clinical outcome of tentorial dural arteriovenous fistula. Front Neurol 2024; 14:1315813. [PMID: 38371305 PMCID: PMC10870646 DOI: 10.3389/fneur.2023.1315813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Introduction To evaluate treatment strategies and clinical outcomes following endovascular embolization of tentorial dural arteriovenous fistulas. Methods We retrospectively analyzed 19 patients with tentorial dural arteriovenous fistulas admitted to the Department of Neurosurgery at Jiangsu Provincial People's Hospital between October 2015 and May 2022, all treated with endovascular therapy. To collect and analyze patients' clinical presentation, imaging data, postoperative complications, and prognosis and to analyze the safety and clinical outcomes of endovascular treatment of tentorial dural arteriovenous fistulas. Results Imaging cure was achieved in 18 patients, with the arterial route chosen for embolization in 17 patients and the venous route in one patient; one patient received partial embolization. Staged embolization was performed in four patients. At postoperative follow-up of 9-83 months (37.8 ± 21.2), all 19 patients had recovered well (mRS score ≤ 2). Three patients experienced perioperative complications: intraoperative Onyx reflux into the middle cerebral artery in one patient; postoperative permanent limited left visual field loss and deafness in the left ear in one patient; and transient diplopia, vertigo, and decreased pain and temperature sensation of the left limb in one patient, with no abnormalities on post-procedure magnetic resonance examinations. A total of 17 patients completed a postoperative digital subtraction angiography review during follow-up, and one patient had a recurrence of an arteriovenous fistula. Conclusion Endovascular treatment of tentorial dural arteriovenous fistulas is safe and effective. Reduction of the Borden or Cognard classification via eliminating cortical venous reflux through multi-staged embolization or combined open surgery is a reasonable goal of treatment where complete obliteration of the fistula is not achievable.
Collapse
Affiliation(s)
- Guangjian Zhang
- Department of Emergency, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Weiwei Zhang
- Department of Ophthalmology, Third Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hanxiao Chang
- Department of Neurosurgery, Jiangsu Province Hospital, Nanjing, China
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuqi Shen
- Department of Neurosurgery, Jiangsu Province Hospital, Nanjing, China
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chencheng Ma
- Department of Neurosurgery, Jiangsu Province Hospital, Nanjing, China
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Mao
- Department of Neurosurgery, Jiangsu Province Hospital, Nanjing, China
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Li
- Department of Neurosurgery, Jiangsu Province Hospital, Nanjing, China
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hua Lu
- Department of Neurosurgery, Jiangsu Province Hospital, Nanjing, China
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
18
|
Becker LS, Dewald CLA, Wacker FK, Hinrichs JB. [Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]. ROFO-FORTSCHR RONTG 2024; 196:163-175. [PMID: 37582384 DOI: 10.1055/a-2124-2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy. METHOD Analysis, summary, and discussion of published review articles and expert recommendations. RESULTS The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance. CONCLUSION Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome. KEY POINTS · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates.. CITATION FORMAT · Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.
Collapse
Affiliation(s)
| | | | - Frank K Wacker
- Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Jan B Hinrichs
- Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
19
|
Holden A, Krauss M, O'Hara R, Jones J, Smith DK. A First-in-Human Trial of a New Aqueous Ionic Liquid Embolic Material in Distal Embolization Applications. J Vasc Interv Radiol 2024; 35:232-240.e1. [PMID: 37931844 DOI: 10.1016/j.jvir.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/12/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE A prospective, single-arm, open-label, multicenter, first-in-human, early feasibility study was completed to evaluate the safety and performance of the GPX Embolic Device (Fluidx, Salt Lake City, Utah), a novel liquid embolic agent, for use in the peripheral vasculature when deep distal embolization is desired. MATERIALS AND METHODS The early feasibility study evaluated the use of the device in the peripheral vasculature. Enrollment consisted of 17 patients with diverse embolization needs requiring deep distal vessel/vessel bed occlusion. Technical success, freedom from adverse events (AEs), and handling/performance characteristics were assessed with follow-up at 30 days. RESULTS The trial enrolled 17 patients requiring distal vascular penetration of the embolic agent, including 7 with renal angiomyolipomas, 4 with renal cell carcinomas (primary and secondary), 4 with portal veins needing embolization, 1 with pelvic sarcoma, and 1 with polycystic kidney. In all cases (100%), technical success was achieved with target regions fully occluded on the first angiogram (taken immediately after delivery). Furthermore, the material received high usability ratings, as measured by a postprocedural investigator questionnaire. Most patients (15/17, 88.2%) were free from device-related severe AEs, and there were no unanticipated AEs during the study. Each patient completed a 30-day follow-up evaluation, and sites remained fully occluded in each case where imaging was available (6 [35.3%] of 17 patients had follow-up imaging where all sites were deemed occluded [100%] with a mean of 30.2 days after the procedure). CONCLUSIONS The results of this first-in-human, early feasibility study demonstrate that the GPX Embolic Device may provide safe and effective embolization for arterial or venous applications where deep distal penetration is desired.
Collapse
Affiliation(s)
- Andrew Holden
- Auckland City Hospital, School of Medicine, University of Auckland, Auckland, New Zealand.
| | - Martin Krauss
- Christchurch Hospital, University of Otago, Christchurch Central City, South Island, New Zealand
| | | | | | | |
Collapse
|
20
|
Li Z, Hou P, Chen Q, Mu S, Li J, Fang Y, Jiang W, Tian X, Wang S. Complex torcular dural arteriovenous fistula leading to cortical venous reflux-induced severe varix and subsequent bilateral cerebral hemispheric hemorrhage: a case report. Front Neurol 2023; 14:1303234. [PMID: 38164200 PMCID: PMC10757922 DOI: 10.3389/fneur.2023.1303234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/24/2023] [Indexed: 01/03/2024] Open
Abstract
Background and importance Dural arteriovenous fistulas (dAVFs) with cortical venous reflux (CVR) are associated with a higher incidence of intracranial hemorrhage (ICH). We report a rare case of a complex torcular dAVF with severe cortical veins (CV) varix leading to extensive bilateral cerebral hemorrhages. This discovery suggests a potential new subtype of dAVF. The case underscores the necessity of a comprehensive understanding of hemodynamic changes in dAVFs and the importance of considering venous compensatory capacity in treatment. This case challenges existing classifications and treatment strategies for dAVFs, highlighting the need for further research and discussion within the neurosurgical community. Clinical presentation A 56-year-old male was admitted to the hospital presenting with dizziness, fatigue, and numbness. Brain CT scans revealed extensive bilateral cerebral hemorrhages. Digital subtraction angiography (DSA) identified a complex torcular dAVF. No cerebral sinus venous thrombosis was detected, but a venous variation in the left transverse sinus was observed. Preoperative DSA demonstrated the patient's well-developed venous compensatory ability. Subsequently, the patient underwent transarterial embolization. The patient made a good recovery. Follow-up DSA and MR angiography at 3 months and 1 year post-treatment showed no recurrence. Conclusion DAVFs are rare lesions, prone to ICH, particularly when CVR is involved. We report a rare case of CVR with severe varix leading to hemorrhagic lesions in both cerebral hemispheres. Our aim is to alert neurosurgical colleagues worldwide to this potential new subtype and to evaluate treatment options, in order to assist those who may encounter such cases in the future.
Collapse
Affiliation(s)
- Ziqi Li
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, Dongfang Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Pengwei Hou
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Qizuan Chen
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Shuwen Mu
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jun Li
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Yi Fang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wenting Jiang
- Fujian Children’s Hospital (Fujian Branch of Shanghai Childre Medical Center), College of Clinical Medicine for Obstetrics Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xinhua Tian
- Department of Neurosurgery, The Affiliated Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Shousen Wang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| |
Collapse
|
21
|
Petrov A, Ivanov A, Kolomin E, Tukanov N, Petrova A, Rozhchenko L, Suvorova J. The Advantages of Non-Adhesive Gel-like Embolic Materials in the Endovascular Treatment of Benign Hypervascularized Lesions of the Head and Neck. Gels 2023; 9:954. [PMID: 38131940 PMCID: PMC10742558 DOI: 10.3390/gels9120954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVES The use of non-adhesive gel-like embolic materials (NAGLEMs) in the endovascular treatment of hypervascularized formations in the head and neck is gaining in popularity because of a number of important characteristics involved. Their primary benefits are their capacity to penetrate diseased vasculature, effectively distribute, and, most importantly, remain controllable during the process. We reviewed the literature and evaluated the results of using NAGLEMs in comparison to other embolizing substances (namely, coils, glue, and particles) as alternative embolizing agents for patients receiving care at our clinic. The process comprised evaluating the safety, effectiveness, and technological elements of endovascular therapy used to treat two categories of hypervascular pathological abnormalities that were surgically corrected between 2015 and 2023. Arteriovenous malformations (AVMs) located in the head, neck, and paragangliomas with jugular/carotid body localization are combined by intense shunting blood flow and shared requirements for the embolic agent used in endovascular treatment (such as penetration, distribution, delayed polymerization, and controllability). An analysis of the literature was also conducted. Results showed 18 patients diagnosed with neck paragangliomas of the carotid body and jugular type. Five patients with arteriovenous malformation (AVM) of the face and neck were included, consisting of sixteen females and seven males with an average age of 55 ± 13 years. Endovascular procedures were performed using NAGLEMs (ONYX (Medtronic, Irvine, CA, USA), SQUID (Balt, Montmorency, France), and PHIL (Microvention, Tustin, CA, USA)) and dimethyl sulfoxide (DMSO)-compatible balloon catheters. All patients achieved complete or partial embolization of hypervascularized formations using one or more stages of endovascular treatment. Additionally, three AVMs of the face and two paragangliomas of the neck were surgically excised following embolization. In other instances, formations were not deemed necessary to be removed. The patients' condition upon discharge was assessed by the modified Rankin Scale (mRs) and rated between 0 and 2. CONCLUSION Currently, NAGLEMs are predominantly used to treat hypervascularized formations in the neck and head due to their fundamental properties. These properties include a lack of adhesion and a delay in predictable polymerization (after 30-40 min). NAGLEMs also exhibit excellent distribution and penetration throughout the vascular bed of the formation. Adequate controllability of the process is largely achieved through the presence of embolism forms of different viscosity, as well as excellent X-ray visualization.
Collapse
Affiliation(s)
- Andrey Petrov
- Vascular Neurosurgery Department, Polenov Neurosurgical Research Institute, Branch of Almazov National Medical Research Centre, 191014 Saint Petersburg, Russia; (A.I.); (E.K.); (N.T.); (A.P.); (L.R.); (J.S.)
- North-Western District Scientific and Clinical Center Named after L. G. Sokolov Federal Medical and Biological Agency, 194291 Saint Petersburg, Russia
| | - Arkady Ivanov
- Vascular Neurosurgery Department, Polenov Neurosurgical Research Institute, Branch of Almazov National Medical Research Centre, 191014 Saint Petersburg, Russia; (A.I.); (E.K.); (N.T.); (A.P.); (L.R.); (J.S.)
- North-Western District Scientific and Clinical Center Named after L. G. Sokolov Federal Medical and Biological Agency, 194291 Saint Petersburg, Russia
| | - Egor Kolomin
- Vascular Neurosurgery Department, Polenov Neurosurgical Research Institute, Branch of Almazov National Medical Research Centre, 191014 Saint Petersburg, Russia; (A.I.); (E.K.); (N.T.); (A.P.); (L.R.); (J.S.)
| | - Nikita Tukanov
- Vascular Neurosurgery Department, Polenov Neurosurgical Research Institute, Branch of Almazov National Medical Research Centre, 191014 Saint Petersburg, Russia; (A.I.); (E.K.); (N.T.); (A.P.); (L.R.); (J.S.)
| | - Anna Petrova
- Vascular Neurosurgery Department, Polenov Neurosurgical Research Institute, Branch of Almazov National Medical Research Centre, 191014 Saint Petersburg, Russia; (A.I.); (E.K.); (N.T.); (A.P.); (L.R.); (J.S.)
| | - Larisa Rozhchenko
- Vascular Neurosurgery Department, Polenov Neurosurgical Research Institute, Branch of Almazov National Medical Research Centre, 191014 Saint Petersburg, Russia; (A.I.); (E.K.); (N.T.); (A.P.); (L.R.); (J.S.)
| | - Julia Suvorova
- Vascular Neurosurgery Department, Polenov Neurosurgical Research Institute, Branch of Almazov National Medical Research Centre, 191014 Saint Petersburg, Russia; (A.I.); (E.K.); (N.T.); (A.P.); (L.R.); (J.S.)
- North-Western District Scientific and Clinical Center Named after L. G. Sokolov Federal Medical and Biological Agency, 194291 Saint Petersburg, Russia
| |
Collapse
|
22
|
Hao Q, Zhang H, Han H, Jin H, Ma L, Li R, Li Z, Li A, Yuan K, Zhu Q, Wang K, Li R, Lin F, Wang C, Zhang Y, Zhang H, Zhao Y, Jin W, Gao D, Guo G, Yan D, Pu J, Kang S, Ye X, Li Y, Sun S, Wang H, Chen Y, Chen X, Zhao Y. Recurrence of Cerebral Arteriovenous Malformation Following Complete Obliteration Through Endovascular Embolization. Transl Stroke Res 2023:10.1007/s12975-023-01215-8. [PMID: 37957446 DOI: 10.1007/s12975-023-01215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
Arteriovenous malformation (AVM) recurrence after embolization was rarely reported. This study aimed to explore the potential risk factors of recurrence in angiographically obliterated AVMs treated with endovascular embolization. This study reviewed AVMs treated with embolization only in a prospective multicenter registry from August 2011 to December 2021, and ultimately included 92 AVMs who had achieved angiographic obliteration. Recurrence was assessed by follow-up digital subtraction angiography (DSA) or magnetic resonance imaging (MRI). Hazard ratios (HRs) with 95% confidence intervals were calculated using Cox proportional hazards regression models. Nineteen AVMs exhibited recurrence on follow-up imaging. The recurrence rates after complete obliteration at 6 months, 1 year, and 2 years were 4.35%, 9.78%, and 13.0%, respectively. Multivariate Cox regression analysis identified diffuse nidus (HR 3.208, 95% CI 1.030-9.997, p=0.044) as an independent risk factor for recurrence. Kaplan-Meier analysis confirmed a higher cumulative risk of recurrence with diffuse nidus (log-rank, p=0.016). Further, in the exploratory analysis of the effect of embolization timing after AVM rupture on recurrence after the complete obliteration, embolization within 7 days of the hemorrhage was found as an independent risk factor (HR 4.797, 95% CI 1.379-16.689, p=0.014). Kaplan-Meier analysis confirmed that embolization within 7 days of the hemorrhage was associated with a higher cumulative risk of recurrence in ruptured AVMs (log-rank, p<0.0001). This study highlights the significance of diffuse nidus as an independent risk factor for recurrence after complete embolization of AVMs. In addition, we identified a potential recurrent risk associated with early embolization in ruptured AVMs.
Collapse
Affiliation(s)
- Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anqi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qinghui Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengzhuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yukun Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Hongwei Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Yang Zhao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Weitao Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Geng Guo
- Department of Emergency, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Xi'an, Shanxi, China
| | - Jun Pu
- Department of Neurosurgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuai Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
23
|
Ch'ng LS, Zaki Z, Sobri Muda A. Embolization of brain arteriovenous malformations with squid co-polymer embolic material: Initial experience. J Interv Med 2023; 6:176-179. [PMID: 38312133 PMCID: PMC10831375 DOI: 10.1016/j.jimed.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/27/2023] [Accepted: 09/27/2023] [Indexed: 02/06/2024] Open
Abstract
Objective To analyze the safety and effectiveness of the ethylene-vinyl alcohol copolymer (EVOH) liquid embolic agent Squid (Emboflu, Switzerland) for the treatment of brain arteriovenous malformations. Materials and procedures Between April 2015 and July 2017, 46 embolization treatments for brain arteriovenous malformations (BAVM) were performed in 25 patients using two Squid formulations (18 and 12). Six female and 19 male patients with a mean age of 34 years (range, 9-62 years) were included. A total of 46 procedures were performed. The BAVMs were classified as Spetzler-Martin grade II in 4 procedures, III in 27 procedures, and 1V in 15 procedures. Among the 25 patients, 15 presented with hemorrhage, 5 with seizures, and 5 with headache and neurology. The BAVMs were located in the temporal lobe in 5 patients, parietal lobe in 7 patients, frontal lobe in 3 patients, posterior fossa in 6 patients, basal ganglia in 3 patients, and parasagittal lobe in 1 patient. Results The obliteration rate of the BAVMs ranged from 10% to 100%, with a mean of 33%. Most patients underwent their first or second embolization procedure. Four patients (8%) developed intracranial bleeding post-procedure, with one death (2%). One patient (2%) experienced a seizure during the procedure; however, no intracranial bleeding was observed. Seven patients (15%) experienced perforations during catheter manipulation. One case (2%) of a fractured catheter was recorded, but no significant complications were observed. The average volume of copolymer injected was 0.6 ml per nidus. Thirteen procedures used the Squid-12 formulation, 29 procedures used the Squid-18 formulation, and 3 procedures used a combination of Squid-12 and -18 formulations. Conclusion Squid is a safe and effective embolic agent for treating BAVMs.
Collapse
Affiliation(s)
- Li Shyan Ch'ng
- Radiology Department, Faculty of Medicine UiTM, Sungai Buloh, Malaysia
| | - Zulkifli Zaki
- Radiology Department, Hospital Sungai Buloh, Sungai Buloh, Malaysia
| | - Ahmad Sobri Muda
- Radiology Department, HSAAS, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| |
Collapse
|
24
|
Shen Y, Wang D, Wen M, Di R, Fan X, Su L, Yang X. Coil-assisted ethanol embolotherapy for refractory head and neck arteriovenous malformations with Onyx recrudescence: 10-Year experiences. J Vasc Surg Venous Lymphat Disord 2023; 11:1219-1230. [PMID: 37473869 DOI: 10.1016/j.jvsv.2023.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/29/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE This study aimed to evaluate the outcomes of coil-assisted ethanol embolotherapy in recanalized head and neck arteriovenous malformations (HNAVMs) with dilated outflowing veins after Onyx treatment. METHODS Thirty-six patients with HNAVMs (18 females and 18 males with a mean age of 26.83 years) who experienced recurrence after Onyx embolization from October 2007 to October 2017 were included in this study. All patients underwent complete clinical and angiographic examinations. Further, each patient was classified based on the Schobinger stage before undergoing staged ethanol embolization. All patients were followed up for 5 years in-person at an interval of 3 months after discharge. The Kaplan-Meier method was used to perform the recurrence-free survival analysis. RESULTS Sixteen patients (44.4%) had Schobinger stage II HNAVMs, and the remaining patients had Schobinger stage III or IV (20/36 patients [55.6%]) HNAVMs. A total of 116 embolization procedures were performed, coils were applied in 107 procedures (92.2%) among patients with dilated outflowing veins. The dose of absolute ethanol was 16.39 mL per procedure in patients with Schobinger II HNAVMs, and 22.45 mL per procedure in patients with Schobinger III and IV HNAVMs (P = .024, 95% confidence interval, 1.128-5.009). During the 3-month evaluation, complete response was observed in 13 of 36 patients (36.1%), and partial response was observed in 23 of 36 patients (63.9%). The 5-year recurrence-free survival rate for patients who underwent Onyx treatment had improved 58.3% after ethanol embolization (95% confidence interval, 2.853-9.595; P < .0001). CONCLUSIONS Coil-assisted ethanol embolotherapy could treat refractory HNAVMs with Onyx recrudescence effectively.
Collapse
Affiliation(s)
- Yuchen Shen
- Vascular Anomaly Center. Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Deming Wang
- Vascular Anomaly Center. Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mingzhe Wen
- Vascular Anomaly Center. Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruoyu Di
- Vascular Anomaly Center. Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xindong Fan
- Vascular Anomaly Center. Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lixin Su
- Fengcheng Hospital of Feng Xian District, Fengcheng Branch, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xitao Yang
- Vascular Anomaly Center. Department of Interventional Therapy, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| |
Collapse
|
25
|
Moosa SS, Hasan H, Leyon JJ, Redha NA, Humaidan H. Things are not what they seem neurologically and radiologically: An apt descriptor for spinal dural arteriovenous fistula (SDAVF). Radiol Case Rep 2023; 18:4123-4129. [PMID: 37745771 PMCID: PMC10511727 DOI: 10.1016/j.radcr.2023.08.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023] Open
Abstract
Spinal dural arteriovenous fistulas (SDAVF) are the most common vascular malformations affecting the spinal cord. It is infrequently encountered in clinical practice and is believed to be acquired, predominantly affecting middle-aged and elderly men with unknown etiology. It is usually misdiagnosed despite presenting with conventional clinical findings and radiological features. Insidious onset of myelopathic findings is seen in addition to pathognomonic findings of cord edema and intrathecal flow voids on MRI. We present a case of SDAVF that was missed by the treating orthopedic surgeon and underwent spinal decompression with subsequent persistence of myelopathic symptoms. Angiography is required to confirm the diagnosis location of the fistula. Treatment is with embolization using liquid embolic agents or surgical through ligation of the draining vein. Endovascular techniques are minimally invasive, safe, and effective. Knowledge of the characteristics and advantages/disadvantages of each agent helps in planning and appropriate selection of agents for the patient. We report successful embolization with improved clinical outcomes for the patient using precipitating hydrophobic injectable liquid (PHIL) embolic agent. The outcome and prognosis of SDAVF depend on the duration of symptoms, severity of neurological symptoms, and successful occlusion of the fistulous draining vein. Awareness of this rare condition amongst clinicians and radiologists, would enable an earlier diagnosis and avoid morbid outcomes of this treatable condition.
Collapse
Affiliation(s)
| | | | - Joe Joseph Leyon
- Department of Radiology, Salmaniya Medical Complex, Manama, Bahrain
| | - Noor Abdulla Redha
- Department of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
| | - Hani Humaidan
- Ibn Al Nafees Hospital, Manama, Bahrain
- Royal Bahrain Hospital, Manama, Bahrain
| |
Collapse
|
26
|
See AP, Smith ER. Evolution of clinical and translational advances in the management of pediatric arteriovenous malformations. Childs Nerv Syst 2023; 39:2807-2818. [PMID: 37462811 DOI: 10.1007/s00381-023-06077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 10/29/2023]
Abstract
Arteriovenous malformations (AVMs) represent one of the most challenging diagnoses in pediatric neurosurgery. Until recently, the majority of AVMs was only identified after hemorrhage and primarily treated with surgery. However, recent advances in a wide range of fields-imaging, surgery, interventional radiology, radiation therapy, and molecular biology-have profoundly advanced the understanding and therapy of these complex lesions. Here we review the progress made in pediatric AVMs with a specific focus on innovations relevant to clinical care.
Collapse
Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA.
| |
Collapse
|
27
|
Saal-Zapata G, Visconti-Lopez FJ. Worldwide Research Trends on Transvenous Embolization of Brain Arteriovenous Malformations: A Bibliometric and Visualized Study. World Neurosurg 2023; 178:20-27. [PMID: 37393998 DOI: 10.1016/j.wneu.2023.06.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Transvenous embolization (TVE) of brain arteriovenous malformations (bAVMs) is an emerging endovascular technique that has shown high cure rates in selected cases. The rationale of our study was to determine authorship and worldwide institutional trends and contributions to the knowledge in this topic. METHODS Web of Science database was used. A total of 63 articles were included based on predefined inclusion criteria, which were manually reviewed. The bibliometric analysis involved the use of quantitative bibliometric indicators and network analysis with co-authorship and co-occurrence of terms, which were performed using the bibliometrix package in R and VOSviewer, respectively. RESULTS The first article was published in 2010, with the largest number of articles published in 2022 (10 articles). The average number of citations per document was 11.38, and the annual growth rate was 14.35%. The top 10 authors with the most scientific production on TVE of bAVMs were from France, and the most cited study was published by Iosif C in 2015, followed by Consoli A in 2013, and Chen CJ in 2018. Journal of Neurointerventional Surgery was the journal with the most articles published. The most commonly used keywords were dural arteriovenous fistula, Onyx, vascular disorders, and neurological surgery around 2016, and intervention around 2021. CONCLUSIONS TVE of bAVMs is an emerging technique. Our search identified some scientific articles, without randomized clinical trials, but many case series from single institutions. French and German institutions are the pioneers in the field, and further research is required in specialized endovascular centers.
Collapse
Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru; Department of Interventional Neurosurgery, Clínica Angloamericana, San Isidro, Lima, Peru
| | | |
Collapse
|
28
|
Lauzier DC, Ullman H, Hardi A, Derdeyn C, Cross DT, Moran CJ. Endovascular treatment of dural arteriovenous fistulas involving the vein of Galen: a single-center cohort and meta-analysis. J Neurointerv Surg 2023:jnis-2023-020843. [PMID: 37777258 DOI: 10.1136/jnis-2023-020843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVFs) draining into the vein of Galen (VoG) are complex lesions that often necessitate treatment to minimize the risk of rupture and relieve symptoms. These lesions can be treated with open surgical resection, radiosurgery, or endovascular embolization. Unfortunately, endovascular treatment of dAVFs involving the VoG has not been robustly assessed across large patient cohorts. To meet this need, we performed a retrospective review of dAVFs involving the VoG at our center, and included these in a meta-analysis to identify the safety and efficacy of endovascular embolization, as well as describing current treatment trends for this disease. METHODS Consecutive patients with dAVFs involving the VoG treated at a single center were identified from a prospective database and retrospectively reviewed. A literature search was conducted with defined search criteria, and eligible studies were included alongside our cohort in a meta-analysis. Rates of complete dAVF treatment and clinical complications were pooled across studies with a random effects model and reported with a 95% CI. RESULTS Five dAVFs involving the VoG were treated endovascularly at our center during the study period. In this series, 80% of treatments led to complete occlusion of the fistula while no patients had clinical complications. Onyx was used for all treatments. In our meta-analysis, the overall rate of complete occlusion was 72.0% (95% CI 59.8% to 84.1%) and the overall rate of clinical complications was 10.0% (95% CI 4.7% to 15.3%). CONCLUSIONS Endovascular approaches for dAVFs involving the VoG are technically feasible, but carry a risk of clinical complications. Future work should identify optimal endovascular embolic agents.
Collapse
Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Henrik Ullman
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Angela Hardi
- Bernard Becker Medical Library, Washington University School of Medicine, St Louis, Missouri, USA
| | - Colin Derdeyn
- Department of Radiology, University of Iowa Medical Center, Iowa City, Iowa, USA
| | - Dewitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology and Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
29
|
Shima S, Ryu B, Sato S, Mochizuki T, Inoue T, Niimi Y. FLOW-diverted Glue Embolization to Target lesions (FLOW-GET) technique for spinal vascular diseases: A technical note. J Neuroradiol 2023; 50:505-510. [PMID: 36967047 DOI: 10.1016/j.neurad.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023]
Abstract
We present and exemplify the flow-diverted glue embolization to target lesions (FLOW-GET) technique for spinal vascular diseases. In this technique, the occlusion of the posterior intercostal artery or dorsal muscular branch by coils diverts the injected glue from the segmental artery to the target lesions. This technique was applied to a ruptured retrocorporeal artery aneurysm and spinal dural arteriovenous fistulas. The FLOW-GET accomplished the complete obliteration of all lesions. This simple and useful technique can be applied to spinal vascular lesions even if a microcatheter is not placed in proper feeders or advanced close to the shunt points or aneurysms.
Collapse
Affiliation(s)
- Shogo Shima
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan.
| | - Bikei Ryu
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan; Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular therapy, St. Luke's International Hospital, Tokyo, Japan
| |
Collapse
|
30
|
Jang H, Jeong ST, Park YC, Kang WS. Nonselective versus Selective Angioembolization for Trauma Patients with Pelvic Injuries Accompanied by Hemorrhage: A Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1492. [PMID: 37629782 PMCID: PMC10456831 DOI: 10.3390/medicina59081492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Angioembolization has emerged as an effective therapeutic approach for pelvic hemorrhages; however, its exact effect size concerning the level of embolized artery remains uncertain. Therefore, we conducted this systematic review and meta-analysis to investigate the effect size of embolization-related pelvic complications after nonselective angioembolization compared to that after selective angioembolization in patients with pelvic injury accompanying hemorrhage. Materials and Methods: Relevant articles were collected by searching the PubMed, EMBASE, and Cochrane databases until 24 June 2023. Meta-analyses were conducted using odds ratios (ORs) for binary outcomes. Quality assessment was conducted using the risk of bias tool in non-randomized studies of interventions. Results: Five studies examining 357 patients were included in the meta-analysis. Embolization-related pelvic complications did not significantly differ between patients with nonselective and selective angioembolization (OR 1.581, 95% confidence interval [CI] 0.592 to 4.225, I2 = 0%). However, in-hospital mortality was more likely to be higher in the nonselective group (OR 2.232, 95% CI 1.014 to 4.913, I2 = 0%) than in the selective group. In the quality assessment, two studies were found to have a moderate risk of bias, whereas two studies exhibited a serious risk of bias. Conclusions: Despite the favorable outcomes observed with nonselective angioembolization concerning embolization-related pelvic complications, determining the exact effect sizes was limited owing to the significant risk of bias and heterogeneity. Nonetheless, the low incidence of ischemic pelvic complications appears to be a promising result.
Collapse
Affiliation(s)
- Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Soon Tak Jeong
- Department of Physical Medicine and Rehabilitation, Ansanhyo Hospital, Ansan-si 15457, Republic of Korea;
| | - Yun Chul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Wu Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Republic of Korea
| |
Collapse
|
31
|
Sioutas GS, Vivanco-Suarez J, Shekhtman O, Matache IM, Salem MM, Burkhardt JK, Srinivasan VM, Jankowitz BT. Liquid embolic agents for middle meningeal artery embolization in chronic subdural hematoma: Institutional experience with systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231183132. [PMID: 37322877 DOI: 10.1177/15910199231183132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles. METHODS We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed. RESULTS A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98-100%), all complications rate was 1% (95% CI: 0-5%), major complications rate was 0% (95% CI: 0-0%), and mortality rate was 1% (95% CI: 0-6%). The rate of hematoma size reduction was 97% (95% CI: 73-100%), complete resolution 64% (95% CI: 33-87%), radiographic recurrence 3% (95% CI: 1-7%), and reoperation 3% (95% CI: 1-7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02-0.95). CONCLUSION MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.
Collapse
Affiliation(s)
- Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Juan Vivanco-Suarez
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Oleg Shekhtman
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Irina-Mihaela Matache
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
- Department of Physiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| |
Collapse
|
32
|
Ognard J, Magro E, Caroff J, Bodani V, Mosimann PJ, Gentric JC. Endovascular Management of Brain Arteriovenous Malformations. Semin Neurol 2023; 43:323-336. [PMID: 37276887 DOI: 10.1055/a-2105-6614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Due to the risk of cerebral hemorrhage, and its related morbidity-mortality, brain arteriovenous malformations (bAVMs) are a rare and potentially life-threatening disease. Despite this, there is only one randomized controlled trial on bAVM management, A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA). The results of the ARUBA trial favor a noninterventional approach in the case of an unruptured bAVM; however, implementation of these findings is challenging in daily practice. Instead, management of bAVM relies on multidisciplinary discussions that lead to patient-specific strategies based on patient preferences, local expertise, and experience in referral centers. Considering the diverse patterns of presentation and numerous treatment modalities, implementing standardized guidelines in this context proves challenging, notwithstanding the recommendations or expert opinions offered. Endovascular treatment (EVT) of bAVM can be curative, or can serve as an adjunct treatment prior to surgery or radiosurgery ("pre-EVT"). EVT practice is in constant evolution (i.e., venous approach, combination with surgery during the same anesthesia, etc.). Liquid embolic agents such as ethylene vinyl alcohol (EVOH) copolymer and cyanoacrylates (CYA), and their method of injection to increase bAVM occlusion have also benefited from technical evolutions such as the use of adjunctive flow arrest techniques (mini balloons, pressure cooker technique, and multiple catheters). Further research is necessary to evaluate the advantages and disadvantages of EVT for bAVM.
Collapse
Affiliation(s)
- Julien Ognard
- Department of Interventional Neuroradiology, Brest University Hospital, Brest, France
- Inserm, UMR 1101 (Laboratoire de Traitement de l'Information Médicale-LaTIM), Université de Bretagne Occidentale, Brest, France
| | - Elsa Magro
- Inserm, UMR 1101 (Laboratoire de Traitement de l'Information Médicale-LaTIM), Université de Bretagne Occidentale, Brest, France
- Department of Neurosurgery, Brest University Hospital, Brest, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Vivek Bodani
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Pascal John Mosimann
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Jean-Christophe Gentric
- Department of Interventional Neuroradiology, Brest University Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Université de Bretagne Occidentale, Brest, France
| |
Collapse
|
33
|
Sahoo A, Abdalkader M, Saatci I, Raymond J, Qiu Z, Huo X, Sun D, Weyland CS, Jia B, Zaidat OO, Hu W, Qureshi AI, Miao Z, Nguyen TN. History of Neurointervention. Semin Neurol 2023; 43:454-465. [PMID: 37549692 DOI: 10.1055/s-0043-1771455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
In this review article, we aim to provide a summary of the discoveries and developments that were instrumental in the evolution of the Neurointerventional field. We begin with developments in the advent of Diagnostic Cerebral Angiography and progress to cerebral aneurysm treatment, embolization in AVMs and ischemic stroke treatment. In the process we discuss many persons who were key in the development and maturation of the field. A pivotal aspect to rapid growth in the field has been the multidisciplinary involvement of the different neuroscience specialties and therefore we close out our discussion with excitement about ongoing and future developments in the field with a focus on treatments in the non-cerebrovascular disease realm.
Collapse
Affiliation(s)
- Anurag Sahoo
- Department of Neurology/Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Mohamad Abdalkader
- Department of Neurology/Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Isil Saatci
- Department of Interventional Neuroradiology, Private Koru Hospitals, Ankara, Turkey
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, People's Republic of China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Charlotte S Weyland
- Department of Interventional Neuroradiology, Aachen University Hospital, Aachen, Germany
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Osama O Zaidat
- Department of Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Wei Hu
- Division of Life Sciences and Medicine, Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, People's Republic of China
| | - Adnan I Qureshi
- Department of Neurology, Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Thanh N Nguyen
- Department of Neurology/Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| |
Collapse
|
34
|
Rolland R, Loubet A, Bommart S, Monnin-Bares V, Zarqane H, Vanoverschelde J, Herman F, Molinari N, Kovacsik H. Safety, Efficacy and Mid-Term Outcome for Transarterial Embolization (TAE) of Renal Angiomyolipoma (AML) Using Ethylene Vinyl Alcohol Copolymer Liquid Embolic Agent (EVOH). J Clin Med 2023; 12:jcm12103385. [PMID: 37240490 DOI: 10.3390/jcm12103385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/06/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Transarterial embolization (TAE) of renal angiomyolipoma (AML) is effective in treating and preventing hemorrhage. We report our experience using EVOH with a single-center retrospective study of all AML embolized with EVOH between June 2013 and March 2022 at the Montpellier University Hospital. A total of 29 embolizations were carried out in 24 consecutive patients (mean age: 53.86 years; 21 women and 3 men) with 25 AMLs for severe bleeding, symptomatic AML, tumor size > 4 cm, or presence of aneurysm(s) > 5 mm. Data collected included imaging and clinical outcomes, tuberous sclerosis complex status, change in AML volume, rebleeding, renal function, volume and concentration of EVOH used, and complications. Out of 29 embolizations performed for 25 AMLs, four were performed in an emergency. Technical success was achieved for 24/25 AMLs. Mean AML volume reduction was 53.59% after a mean follow-up time of 446 days using MRI or CT scan. Aneurysms on angiogram and the symptomatological nature of AML, as well as secondary TAE and multiple arterial pedicles, were statistically associated (p < 0.05). Two patients (8%) underwent nephrectomy after TAE. Four patients had a second embolization. Minor and major complication rates were 12% and 8%, respectively. Neither rebleeding nor renal function impairment was noticed. TAE of AML using EVOH is, thus, highly effective and safe.
Collapse
Affiliation(s)
- Rémi Rolland
- Department of Radiology, CHU of Montpellier, Arnaud de Villeneuve Hospital, 34090 Montpellier, France
| | - Antoine Loubet
- Department of Radiology, CHU of Montpellier, Arnaud de Villeneuve Hospital, 34090 Montpellier, France
| | - Sébastien Bommart
- Department of Radiology, CHU of Montpellier, Arnaud de Villeneuve Hospital, 34090 Montpellier, France
| | - Valérie Monnin-Bares
- Department of Radiology, CHU of Montpellier, Arnaud de Villeneuve Hospital, 34090 Montpellier, France
| | - Hamid Zarqane
- Department of Radiology, CHU of Montpellier, Arnaud de Villeneuve Hospital, 34090 Montpellier, France
| | - Juliette Vanoverschelde
- Department of Radiology, CHU of Montpellier, Arnaud de Villeneuve Hospital, 34090 Montpellier, France
| | - Fanchon Herman
- Department of Medical Statistics and Epidemiology, Centre Hospitalier Universitaire Montpellier, University of Montpellier, 34090 Montpellier, France
| | - Nicolas Molinari
- Department of Medical Statistics and Epidemiology, Centre Hospitalier Universitaire Montpellier, University of Montpellier, 34090 Montpellier, France
| | - Hélène Kovacsik
- Department of Radiology, CHU of Montpellier, Arnaud de Villeneuve Hospital, 34090 Montpellier, France
| |
Collapse
|
35
|
Tannai H, Oguro S, Nagao M, Ota H, Takase K. High-flow arteriovenous malformation in the finger with transvenous ethanolamine oleate sclerotherapy using an arterial tourniquet and microballoon occlusion: A case report. Radiol Case Rep 2023; 18:1973-1977. [PMID: 36970241 PMCID: PMC10036881 DOI: 10.1016/j.radcr.2023.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/22/2023] Open
Abstract
Endovascular therapy is an important method of treating high-flow arteriovenous malformations (AVMs). The nidus of AVMs can be treated by transarterial or percutaneous approaches with the use of ethanol as a strong embolic agent; however, treatment outcomes are not always satisfactory and complications including skin necrosis often occur, particularly following the treatment of superficial lesions. Herein, we describe successful transvenous sclerotherapy of high-flow AVMs in the finger of a 47-year-old female patient that were causing erythema and spontaneous pain using ethanolamine oleate (EO) as a safe sclerosant. Dynamic contrast-enhanced computed tomography and angiography revealed a high-flow type Ⅲb AVM according to Yakes classification. Using the transvenous approach, 5% EO with idoxanol was injected into the nidus of the AVM 3 times over 2 sessions. An arterial tourniquet was used to achieve stasis of blood flow at the nidus and microballoon occlusion of the outflow vein was used to ensure the sclerosant effectively reached the nidus. Near-total occlusion of the nidus was achieved leading to improved symptoms. Mild edema lasting 2 weeks occurred as a minor reaction after each session. Finger amputation may have been avoided by using this treatment. Transvenous EO sclerotherapy using an arterial tourniquet and balloon occlusion may have utility in treating AVMs in the extremities.
Collapse
Affiliation(s)
- Hiromitsu Tannai
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, 2...1 Seiryo...machi, Aoba...ku, Sendai, Miyagi, 980-8575, Japan
| | - Sota Oguro
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, 2...1 Seiryo...machi, Aoba...ku, Sendai, Miyagi, 980-8575, Japan
- Corresponding author.
| | - Munetomo Nagao
- Department of Plastic and Reconstructive Surgery, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, 2...1 Seiryo...machi, Aoba...ku, Sendai, Miyagi, 980-8575, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, 2...1 Seiryo...machi, Aoba...ku, Sendai, Miyagi, 980-8575, Japan
| |
Collapse
|
36
|
Desir LL, Narayan V, Ellis J, Gordon D, Langer D, Ortiz R, Serulle Y. Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature. Curr Neurol Neurosci Rep 2023; 23:109-119. [PMID: 37037979 DOI: 10.1007/s11910-023-01262-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. RECENT FINDINGS Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.
Collapse
Affiliation(s)
- Likowsky L Desir
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
- City University of New York School of Medicine, New York, NY, USA
| | - Vinayak Narayan
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Jason Ellis
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Gordon
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Rafael Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Yafell Serulle
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA.
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Neuroendovascular Surgery, Phelps Hospital, Sleepy Hollow, NY, USA.
| |
Collapse
|
37
|
Zeleňák K, Šalát D, Kolarovszki B, Kurča E, Zeleňáková J, Koçer N. Embolization of Ruptured Infratentorial Pial AVM in Pregnancy. Life (Basel) 2023; 13:life13040896. [PMID: 37109425 PMCID: PMC10144631 DOI: 10.3390/life13040896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/12/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
A primigravida 22-year-old woman, at a gestation of 23 weeks, experienced bleeding from a pial arteriovenous malformation (AVM) located in the right cerebellum. After interdisciplinary consensus and with the informed consent of the patient and her family, AVM embolization was performed. Complete occlusion of the AVM was achieved by embolization with PHIL (precipitating hydrophobic injectable liquid). The calculated dose in the uterus was less than 1 µSv, which represents a negligible risk of harmful effects on the fetus. She delivered a baby at 37 weeks of gestation by cesarean section without complications. No congenital disorders were diagnosed by standard screening methods until the age of the newborn was two years. The angiography protocol must be optimized to minimize the radiation dose. Adequate shielding protection of the uterus is important. Premature termination of pregnancy is not necessary. Multidisciplinary care of neurologists, neurosurgeons, interventional radiologists, anesthesiologists, neonatologists, and obstetricians is necessary.
Collapse
|
38
|
Szmygin M, Szmygin P, Drelich K, Pustelniak O, Pech M, Jargiełło T. The role of interventional radiology in treatment of patients with hereditary hemorrhagic telangiectasia. Eur J Radiol 2023; 162:110769. [PMID: 36933496 DOI: 10.1016/j.ejrad.2023.110769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu disease is a rare autosomal dominant, multi-organ disorder that leads to formation of abnormal vascular connections resulting in devastating and life-threatening complications. Due to its multisystem character, wide range of clinical manifestations and variable expressivity, HHT remains a diagnostic challenge and requires close cooperation of specialists from various medical fields. Interventional radiology plays a key role in the management of this disease, helping maintain the health of HHT patients and minimize the risk of fatal complications. The aim of this article is to review clinical manifestations, diagnostic guidelines and criteria of HHT as well as to present the means of endovascular therapy in the management of HHT patients.
Collapse
Affiliation(s)
- Maciej Szmygin
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland.
| | - Paweł Szmygin
- Medical University of Lublin, Department of Neurosurgery, Lublin, Poland
| | - Katarzyna Drelich
- Medical University of Lublin, Students' Scientific Society at the Department of Interventional Radiology and Neuroradiology, Lublin, Poland
| | - Olga Pustelniak
- Medical University of Lublin, Students' Scientific Society at the Department of Interventional Radiology and Neuroradiology, Lublin, Poland
| | - Maciej Pech
- Medical University of Magdeburg, Department of Radiology and Nuclear Medicine, Magdeburg, Germany
| | - Tomasz Jargiełło
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland
| |
Collapse
|
39
|
Endovascular treatment of spinal AVM: report of two cases with transvenous approach in combination with retrograde pressure cooker technique. Neuroradiology 2023; 65:961-968. [PMID: 36862187 PMCID: PMC10105665 DOI: 10.1007/s00234-023-03132-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/05/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Endovascular treatment of spinal AVMs is limited by low complete cure rates. Transarterial extensive treatment with liquid embolics carries the risk of clinically relevant ischemic complications. We report two cases of symptomatic spinal AVMs treated by a transvenous approach with retrograde pressure cooker technique. METHODS In two selected cases, transvenous navigation aimed at retrograde pressure cooker embolization. RESULTS Retrograde venous navigation was possible with two parallel microcatheters, and the pressure cooker technique with ethylenvinylalcohol-polymer was applicable in both cases. One AVM was occluded completely, and one subtotally due to a second draining vein. No clinical complications occurred. CONCLUSION A transvenous approach for embolization with liquid embolics may offer advantages in treating certain spinal AVMs.
Collapse
|
40
|
Rheological Properties of Non-Adhesive Embolizing Compounds-The Key to Fine-Tuning Embolization Process-Modeling in Endovascular Surgery. Polymers (Basel) 2023; 15:polym15041060. [PMID: 36850343 PMCID: PMC9966492 DOI: 10.3390/polym15041060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023] Open
Abstract
The study of polymers' rheological properties is of paramount importance both for the problems of their industrial production as well as for their practical application. Two polymers used for embolization of arteriovenous malformations (AVMs) are studied in this work: Onyx-18® and Squid-12®. Viscosity curve tests and computational fluid dynamics (CFD) were used to uncover viscosity law as a function of shear rate as well as behavior of the polymers in catheter or pathological tissue models. The property of thermal activation of viscosity was demonstrated, namely, the law of dependence of viscosity on temperature in the range from 20 °C to 37 °C was established. A zone of viscosity nonmonotonicity was identified, and a physical interpretation of the dependence of the embolic polymers' viscosity on the shear rate was given on the basis of Cisco's model. The obtained empirical constants will be useful for researchers based on the CFD of AVMs. A description of the process of temperature activation of the embolic polymers' viscosity is important for understanding the mechanics of the embolization process by practicing surgeons as well as for producing new prospective embolic agents.
Collapse
|
41
|
Yahia-Cherif M, Fenton C, Bonnet T, De Witte O, Simon S, De Maertelaer V, Mine B, Lefranc F, Lubicz B. Embolization before Gamma Knife radiosurgery for cerebral arteriovenous malformations does not negatively impact its obliteration rate: a series of 190 patients. Neuroradiology 2023; 65:391-399. [PMID: 36271057 DOI: 10.1007/s00234-022-03066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/09/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Embolization of arteriovenous malformations (AVMs) before radiosurgery has been reported to negatively impact the obliteration rate. This study aims to assess treatment outcomes in a series of 190 patients treated by Gamma Knife radiosurgery (GKRS) for previously embolized AVMs. METHODS The institutional database of AVMs was retrospectively reviewed between January 2004 and March 2018. The clinical and radiological data of patients treated with GKRS for previously embolized AVMs were analyzed. Predicting factors of obliteration and hemorrhage following GKRS were assessed with univariate and multivariate regression analyses. RESULTS The mean AVM size was significantly reduced after embolization (p < 0.001). The obliteration rate was 78.4%. Multivariate analyses showed that a lower Spetzler-Martin grade (p = 0.035) and a higher marginal dose (p = 0.007) were associated with obliteration. Post-GKRS hemorrhages occurred in 14 patients (7.4%). A longer time between diagnosis and GKRS was the only factor associated with post-GKRS hemorrhages in multivariate analysis (p = 0.022). Complications related to the combined treatment were responsible for a new permanent neurological disability in 20 patients (10.5%), and a case of death (0.5%). CONCLUSIONS This study shows that the embolization of AVMs does not have a negative impact on the obliteration rate after radiosurgery. Embolization reduces the AVM size to a treatable volume by GKRS. However, the combined treatment results in an increased complication rate related to the addition of the risks of each treatment modality.
Collapse
Affiliation(s)
- Mehdi Yahia-Cherif
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium.
| | - Chifra Fenton
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier De Witte
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium
| | - Stéphane Simon
- Department of Medical Physics, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Viviane De Maertelaer
- Department of Biostatistics, IRIBHM, Université Libre de Bruxelles, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Florence Lefranc
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
42
|
Stewart RJ, Sima M, Karz J, Jones JP. Material characterization of GPX ®: A versatile in situ solidifying embolic platform technology. Front Bioeng Biotechnol 2023; 11:1095148. [PMID: 36726745 PMCID: PMC9885798 DOI: 10.3389/fbioe.2023.1095148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023] Open
Abstract
Endovascular embolization is a minimally invasive procedure during which blood flow to targeted tissues is selectively occluded. The list of clinical indications for embolization continues to expand. Liquid embolic agents are injectable compositions that transition into a solid or semi-solid form when introduced into blood vessels. The mechanism that triggers the liquid-to-solid transition is a key distinguishing feature of liquid embolic agents. GPX is a waterborne liquid embolic agent comprising oppositely charged polyelectrolytes: polyguanidinum and inorganic polyphoshate. In situ solidification is driven by electrostatic condensation of the polyelectrolytes, triggered by ionic strength differentials. We report in vitro characterization of the material properties of GPX, it is in vivo effectiveness in acute animal studies, and its potential for chemoembolization. The viscosity of GPX can be varied over a wide range by adjusting the polyguanidinium MW and/or concentration. Formulation of GPX with either tantalum microparticles (30 wt%) or iodinated radiocontrast agents (300 mgI ml-1) did not significantly change the flow behavior of GPX; the viscosity was independent of shear rate and remained within a clinically practical range (80-160 cP). Formulation of GPX with doxorubicin substantially increased viscosity at low shear rates and resulted in a power law dependence on shear rate. High contrast and effective vascular occlusion were demonstrated in both swine kidneys and rete mirabile. Contrast from iodinated compounds was temporary, dissipating within hours. The doxorubicin in vitro release profile was linear over 90 days. The results demonstrate that GPX is a versatile liquid embolic platform that can be formulated with a wide range of viscosities injectable at clinically practical flow rates, with either transient or permanent contrast, and that can provide prolonged zero-order delivery of doxorubicin to embolized tissues.
Collapse
Affiliation(s)
- Russell J. Stewart
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States,*Correspondence: Russell J. Stewart,
| | - Monika Sima
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Jessica Karz
- Fluidx Medical Technology, Inc., Salt Lake City, UT, United States
| | - Joshua P. Jones
- Fluidx Medical Technology, Inc., Salt Lake City, UT, United States
| |
Collapse
|
43
|
Wagenpfeil J, Kütting D. [Radiological embolization procedures in acute gastrointestinal, peritoneal and muscular hemorrhage]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:11-17. [PMID: 36355070 DOI: 10.1007/s00117-022-01086-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Treatment of acute hemorrhage is particularly challenging due to its sudden onset and the fact that it is often life-threatening. Potential causes include bleeding ulcerations of the gastrointestinal tract or tumor bleeding, but acute bleeding can also occur spontaneously or be traumatic, iatrogenic, or inflammatory. OBJECTIVE To demonstrate the basic principles of catheter embolization, as well as various embolic materials and their properties. RESULTS Today there are a wide range of embolization materials available. Ultimately the duration and extent of the desired occlusion are decisive when selecting an embolic material. Mechanical occlusion devices, particulates, and liquid embolic agents are available. CONCLUSION Irrespective of the wide range of different etiologies, radiological embolization therapy is a very safe treatment option in cases of computed tomographic evidence of active hemorrhage. Ultimately, the interventionalist's comprehensive knowledge of the relevant characteristics is crucial for the success of therapy.
Collapse
Affiliation(s)
- J Wagenpfeil
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - D Kütting
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| |
Collapse
|
44
|
State of the Art in the Role of Endovascular Embolization in the Management of Brain Arteriovenous Malformations-A Systematic Review. J Clin Med 2022; 11:jcm11237208. [PMID: 36498782 PMCID: PMC9739246 DOI: 10.3390/jcm11237208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
As a significant cause of intracerebral hemorrhages, seizures, and neurological decline, brain arteriovenous malformations (bAVMs) are a rare group of complex vascular lesions with devastating implications for patients' quality of life. Although the concerted effort of the scientific community has improved our understanding of bAVM biology, the exact mechanism continues to be elucidated. Furthermore, to this day, due to the high heterogeneity of bAVMs as well as the lack of objective data brought by the lack of evaluative and comparative studies, there is no clear consensus on the treatment of this life-threatening and dynamic disease. As a consequence, patients often fall short of obtaining the optimal treatment. Endovascular embolization is an inherent part of multidisciplinary bAVM management that can be used in various clinical scenarios, each with different objectives. Well-trained neuro-interventional centers are proficient at curing bAVMs that are smaller than 3 cm; are located superficially in noneloquent areas; and have fewer, larger, and less tortuous feeding arteries. The transvenous approach is an emerging effective and safe technique that potentially offers a chance to cure previously untreatable bAVMs. This review provides the state of the art in all aspects of endovascular embolization in the management of bAVMs.
Collapse
|
45
|
Ku JC, Dobashi Y, Pasarikovski CR, Ramjist J, Hamani C, Heyn C, Walus K, Yang VXD. Photosensitive Hydrogel-Based Embolic Agent Treatment of Wide-Necked Aneurysms: Preliminary Animal Results. Gels 2022; 8:gels8120788. [PMID: 36547312 PMCID: PMC9778217 DOI: 10.3390/gels8120788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background: The endovascular treatment of cerebral aneurysms has become widespread but may still be limited by recurrence rates or complications. The discovery of novel embolic strategies may help mitigate these concerns. Methods: We formulated a Photosensitive Hydrogel Polymer (PHP) embolic agent which is low-viscosity, shear-thinning, and radio-opaque. After the filling of an aneurysm with PHP with balloon assistance, we utilized photopolymerization to induce solidification. Different methods of light delivery for photopolymerization were assessed in silicone models of aneurysms and in four acute animal trials with venous anastomosis aneurysms in pigs. Then, balloon-assisted embolization with PHP and photopolymerization was performed in three aneurysms in pigs with a one-month follow-up. Filling volume, recurrence rates, and complications were recorded. Results: The PHP was found to be suitable for the intravascular delivery and treatment of cerebral aneurysms. It was found that light delivery through the balloon catheter, as opposed to light delivery through the injection microcatheter, led to higher rates of filling in the 3D model and acute animal model for cerebral aneurysms. Using the balloon-assisted embolization and light delivery strategy, three wide-necked aneurysms were treated without complication. One-month follow-up showed no recurrence or neck remnants. Conclusions: We demonstrated a novel method of balloon-assisted photosensitive hydrogel polymer embolization and photopolymerization, leading to complete aneurysm filling with no recurrence at 1 month in three wide-necked aneurysms in pigs. This promising methodology will be investigated further with longer-term comparative animal trials.
Collapse
Affiliation(s)
- Jerry C. Ku
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
- Correspondence:
| | - Yuta Dobashi
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
| | | | - Joel Ramjist
- Department of Electrical, Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON M5B 2K3, Canada
| | - Clement Hamani
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Chinthaka Heyn
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
- Division of Neuroradiology, Department of Radiology, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Konrad Walus
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Victor X. D. Yang
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Electrical, Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON M5B 2K3, Canada
- Division of Neurosurgery, Department of Clinical Neurological Sciences, Schulich School of Medicine, Western University, London, ON N6A 3K7, Canada
| |
Collapse
|
46
|
Schmitt N, Wucherpfennig L, Hohenstatt S, Karimian-Jazi K, Breckwoldt MO, Kauczor HU, Bendszus M, Möhlenbruch MA, Vollherbst DF. Material-Specific Roadmap Modes Can Improve the Visibility of Liquid Embolic Agents for Endovascular Embolization: A Systematic In Vitro Study. AJNR Am J Neuroradiol 2022; 43:1749-1755. [PMID: 36357152 DOI: 10.3174/ajnr.a7706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/12/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular embolization using liquid embolic agents is a safe and effective treatment option for AVMs and fistulas. Because reliable visibility of these liquid embolic agents is essential for intraprocedural visual control to prevent complications, novel angiographic systems are equipped with material-specific roadmap modes. The aim of this study was the systematic in vitro comparison of conventional and material-specific roadmap modes regarding the visibility of the most used liquid embolic agents. MATERIALS AND METHODS A recently introduced in vitro model, resembling cerebral vessels, was embolized with Onyx 18, Squid 18, PHIL 25%, and n-BCA mixed with iodized oil (n = 4 for each liquid embolic agent), as well as with contrast medium and saline, both serving as a reference. Imaging was performed in conventional and material-specific roadmap modes. The visibility of the liquid embolic agents in both modes was compared quantitatively and qualitatively. RESULTS Significant differences between conventional and material-specific roadmap modes regarding the visibility of the liquid embolic agents were observed for all study groups. All liquid embolic agents were better visible in the material-specific roadmap modes compared with the conventional mode in qualitative and quantitative analyses (eg, Onyx in conventional-versus-material-specific modes along the 1.0-mm sector: mean contrast-to-noise ratio, 5.69 [SD, 0.85] versus 47.18 [SD, 5.72]; P < .001, respectively). CONCLUSIONS In this in vitro study, we demonstrated a better visibility of all investigated liquid embolic agents by using material-specific roadmap modes compared with the conventional roadmap technique. Especially in complex anatomic situations, these novel roadmap modes could improve the visual control and thus the safety and efficacy of embolization procedures in clinical practice.
Collapse
Affiliation(s)
- N Schmitt
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - L Wucherpfennig
- Diagnostic and Interventional Radiology (L.W., H.-U.K.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Hohenstatt
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - K Karimian-Jazi
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - M O Breckwoldt
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - H-U Kauczor
- Diagnostic and Interventional Radiology (L.W., H.-U.K.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - D F Vollherbst
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| |
Collapse
|
47
|
Hou K, Lv X, Guo Y, Yu J. Endovascular treatment of posterior inferior cerebellar artery trunk aneurysm. Acta Neurol Belg 2022; 122:1405-1417. [PMID: 34677822 DOI: 10.1007/s13760-021-01826-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The posterior inferior cerebellar artery (PICA) generally originates from the vertebral artery (VA) and is the most complex cerebellar artery. Aneurysms can occur at any site along the PICA trunk. Although most PICA aneurysms are located at the VA-PICA junction, a small proportion is located at the PICA trunk. Endovascular treatment (EVT) of aneurysms in the PICA trunk may be difficult and complex. METHODS We performed a review to expound upon EVT of PICA trunk aneurysms. RESULTS The PICA can be divided into five segments (p1-5); the p1-3 segments are proximal segments, and the p4-5 segments are distal segments. Most PICA trunk aneurysms are dissecting aneurysms. Sometimes, the PICA can give rise to flow-related aneurysms in association with cerebellar arteriovenous malformations. Most aneurysms of the PICA trunk require aggressive treatment, especially those that have ruptured. Currently, the EVT mainly includes selective coiling with/without stent assistance and parent artery occlusion. Recently, some new devices, such as flow diversion and Barricade and Kaneka ED coils, can be used to treat PICA trunk aneurysms. The risk of complications with EVT seems to be higher; however, most complications are only transient or mild, and some are even clinically silent. In addition, open surgery is still an important option. CONCLUSION For PICA trunk aneurysms, the treatment choice should be assessed on a case-by-case basis. The rate of permanent morbidity of the EVT is low. EVT is an effective method for treating PICA trunk aneurysms.
Collapse
Affiliation(s)
- Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Yunbao Guo
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China.
| |
Collapse
|
48
|
Angiogenetic Factors in Chronic Subdural Hematoma Development. Diagnostics (Basel) 2022; 12:diagnostics12112787. [PMID: 36428849 PMCID: PMC9689028 DOI: 10.3390/diagnostics12112787] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/15/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
The levels of angiogenic factors were analyzed in eight patients who underwent the embolization of chronic subdural hematoma (CSDH) with non-adhesive liquid embolic agents. Four of these patients had previously undergone surgical treatment for hematoma removal and had recurrences of a similar volume, and four had an increase in hematoma volume due to rebleeding. The levels of vascular endothelial growth factor (VEGF), matrix metallopeptidase 9 (MMP 9), angiopoietin-2 (Ang2), transforming growth factor beta 1 (TGF-β1) and platelet-derived growth factor BB (PDGF-BB) in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The levels of VEGF in the samples of all the patients were close to normal or slightly decreased. There was an increase in the MMP9 levels (the factor that contributes to the disintegration of the vessel wall components) in all the patients. The Ang2 and especially the PDGF TGF-β1 (the factor that plays an important role in the growth of the vessel wall from the already existing blood vessel tissue) levels were distinctly low in most of the cases and slightly elevated only in a number of patients who had previously been operated on. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. At the same time, the factors determining the formation of the vessel wall were reduced, and the levels of factors contributing to the degradation of extracellular matrix components were significantly increased. Such factors could help us to anticipate the increased risk of hemorrhages. Highlights: The levels of VEGF, MMP 9, Ang2, TGF-β1 and PDGF-BB in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. Such a profile of factors could help us to anticipate the increased risk of hemorrhages.
Collapse
|
49
|
Tu T, Song Z, Ma Y, Yang C, Su X, He C, Li G, Hong T, Sun L, Hu P, Zhang P, Ye M, Zhang H. Adult dural arteriovenous fistulas in Galen region: More to be rediscovered. Front Neurol 2022; 13:957713. [PMID: 36388187 PMCID: PMC9650976 DOI: 10.3389/fneur.2022.957713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/26/2022] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVFs) in the Galen region are the most deeply located and most complex type of dural arteriovenous fistulas. However, cases of DAVFs in this region have not been well described. Thus, we aimed to summarize the characteristics of Galenic DAVFs involving clinical symptoms, anatomical architecture, and drainage patterns, providing experientially therapeutic strategies for these lesions based on our 20 years of clinical experience. METHODS We retrospectively examined 31 patients with Galenic DAVFs between January 2000 and June 2021. A comprehensive analysis was carried out based on the symptoms, imaging features, feeding arteries, draining veins, number and location of the fistulas, choice of treatment methods, and prognosis assessment. RESULTS Twenty-nine patients received endovascular embolization, and no perioperative deaths occurred. A transarterial approach was performed in 27 patients, and a combined transarterial and transvenous approach in one. And in one case, access was established by surgical drilling and embolization was done via the venous route. Twenty-four cases were completely obliterated after first embolization, and another five cases received a second period treatment. Only one patient developed cognitive dysfunction after embolization, and the outcomes of the remaining patients were improved at long-term follow-up. CONCLUSION The understanding of symptoms of non-hemorrhagic neurological deficits in DAVF needs to be further clarified. Lesions with pial feeders may be considered first when determining surgical orders. Multi-approach and multi-stage embolization would be safe and effective. Excessive embolization and deep-vein system obstruction should be avoided. Approach creation by surgery would be an innovative interventional therapy.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
50
|
Gluing blood into gel by electrostatic interaction using a water-soluble polymer as an embolic agent. Proc Natl Acad Sci U S A 2022; 119:e2206685119. [PMID: 36215508 PMCID: PMC9586266 DOI: 10.1073/pnas.2206685119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Liquid embolic agents are widely used for the endovascular embolization of vascular conditions. However, embolization based on phase transition is limited by the adhesion of the microcatheter to the embolic agent, use of an organic solvent, unintentional catheter retention, and other complications. By mimicking thrombus formation, a water-soluble polymer that rapidly glues blood into a gel without triggering coagulation was developed. The polymer, which consists of cationic and aromatic residues with adjacent sequences, shows electrostatic adhesion with negatively charged blood substances in a physiological environment, while common polycations cannot. Aqueous polymer solutions are injectable through clinical microcatheters and needles. The formed blood gel neither adhered to the catheter nor blocked the port. Postoperative computed tomography imaging showed that the polymer can block the rat femoral artery in vivo and remain at the injection site without nontarget embolization. This study provides an alternative for the development of waterborne embolic agents.
Collapse
|