Trans-arterial embolisation therapy of dural carotid-cavernous fistulae using low concentration n-butyl-cyanoacrylate

Endovascular management of cavernous sinus dural arteriovenous fistulas: Overall review and considerations

Cavernous sinus dural arteriovenous fistulas (CSDAVFs) are arteriovenous shunts between small dural branches arising from the external and/or internal carotid arteries and the cavernous sinus (CS). And now a days, endovascular treatment is the treatment of choice in CSDAVF. We review the anatomy and classifications of CSDAVFs, discussing and detailing these considerations in the treatment of CSDAVFs, theoretically and in the light of recent literatures.

The road less traveled: transarterial embolization of dural arteriovenous fistulas via the ascending pharyngeal artery

Background

With the introduction of Onyx, transarterial embolization has become the most common endovascular approach to treating dural arteriovenous fistulas (dAVFs), often via the middle meningeal or occipital arteries. The ascending pharyngeal artery (APA) is a less frequently explored transarterial route because of its small caliber, potential anastomoses to the internal carotid and vertebral arteries, and vital supply to lower cranial nerves.

Objective

To review our institutional experience and highlight the prevalence of APA supply to dAVFs and cases where it is a safe and effective pedicle for embolization.

Methods

We reviewed our endovascular database (January 1, 1996 to March 1, 2016) for cranial dAVFs, evaluating dAVF characteristics and embolization results for those treated transarterially via the APA.

Results

Of 267 endovascularly treated dAVFs, 68 had APA supply (25%). Of these 68 dAVFs, embolization was carried out via this pedicle in 8 (12%) and 7 were ultimately occluded. No complications, including post-treatment cranial neuropathies or radiographic evidence of non-target embolization, were found. For 5 dAVFs, the APA was selected as the initial pedicle for embolization (two marginal sinus, one distal sigmoid, one cavernous, one tentorial). In four of these five cases, dAVF occlusion was achieved via the initial APA feeding artery pedicle. In one case, near-complete, stagnant occlusion was achieved after APA embolization; complete occlusion was achieved after adjunctive embolization of a single additional middle meningeal artery pedicle. In three other cases of complex transverse/sigmoid dAVFs, the APA was used after multiple attempts via middle meningeal and occipital artery pedicles. Occlusion was not achieved transarterially; two of these three dAVFs were ultimately occluded transvenously.

Conclusions

In rare, select cases, the APA is an excellent route for transarterial embolization of cranial dAVFs.

Preliminary findings of arterial embolization with balloon-occluded and flow-dependent histoacryl glue embolization in a swine model

PURPOSE

To evaluate the potential usefulness of the balloon-occluded histoacryl glue embolization (B-glue) technique.

MATERIALS AND METHODS

Both flow-dependent (no balloon occlusion) and B-glue techniques were used for 24 intercostal arteries of two female swine. N-butyl 2-cyanoacrylate (NBCA) was diluted with lipiodol to a 50 % solution, which was infused after occluding the arteries with microballoon catheters. The embolization range, fragmentation, reflux, adhesion, and glue particle attachment were compared between flow-dependent and B-glue techniques.

RESULTS

The B-glue technique was performed in a controlled fashion resulting in successful arterial occlusion without fragmented migration of the injected glue cast. Reflux occurred less frequently with the B-glue technique and was significantly different (p = 0.039) [Corrected] from that for the flow-dependent technique. Catheters were safely removed from the arterial walls, although in one instance (8.3 %), large glue particles were found to be attached to the catheter tip on removal. Conversely, the flow-dependent technique was more difficult to control and resulted in several instances of higher rates of fragmentation.

CONCLUSION

The B-glue technique can efficiently control NBCA delivery with lower rates of reflux.

Efficacy and limitations of transarterial acrylic glue embolization for intracranial dural arteriovenous fistulas

The efficacy and limitations of transarterial acrylic glue embolization for the treatment of intracranial dural arteriovenous fistulas (DAVFs) were investigated. Thirty-four DAVFs treated by transarterial embolization using n-butyl cyanoacrylate were retrospectively reviewed. The locations of DAVFs were the transverse-sigmoid sinus in 11, tentorium in 10, cranial vault in 9, and superior sagittal sinus, jugular bulb, foramen magnum, and middle cranial fossa in 1 each. Borden classification was type I in 7, type II in 3, and type III in 24. Eight patients had undergone prior transvenous coil embolization. Complete obliteration rate was 56% immediately after embolization, 71% at follow-up angiography, and 85% after additional treatments (1 transvenous embolization and 4 direct surgery). Complications occurred in three patients, consisting of asymptomatic vessel perforations during cannulation in two patients and leakage of contrast medium resulting in medullary infarction in one patient. Transarterial glue embolization is highly effective for Borden type III DAVF with direct cortical venous drainage, but has limitations for Borden type I and II DAVFs in which the affected sinus is part of the normal venous circulation. Onyx is a new liquid embolic material and is becoming the treatment of choice for DAVF. The benefits of glue embolization compared to Onyx embolization are high thrombogenicity, and relatively low risks of cranial nerve palsies and of excessive migration into the draining veins of high flow fistula. Transarterial glue embolization continues to be useful for selected patients, and complete cure can be expected in most patients with fewer complications if combined with transvenous embolization or direct surgery.

Long-Term Endovascular Treatment Outcome of 46 Patients with Cavernous Sinus Dural Arteriovenous Fistulas Presenting with Ophthalmic Symptoms. A Non-Controlled Trial with Clinical and Angiographic Follow-up

Ocular symptoms are regularly observed in patients with cavernous sinus dural arteriovenous fistulas (cDAVF). We aimed to evaluate the long-term efficacy and safety of endovascular approaches in patients with cDAVF presenting with different ocular symptoms. In a prospective study between June 2008 and March 2013, 46 patients with ocular symptoms due to cDAVF who were not eligible for conservative therapy, met the inclusion criteria and underwent endovascular treatment. They underwent a transarterial approach with histoacryl glue injections or transvenous coil embolization, all in one session. They were followed up for a mean period of 17.3 months (range 7 to 30 months) clinically and using angiography. The mean age of patients was 36.8 years (18-60) and 65% of them were male. All patients showed venous drainage into the superior and inferior orbital veins. Access to the cavernous sinus was transvenous in ten patients, transarterial in 26 patients, and mixed in ten patients. Initial symptoms were improved in 97.8% of patients and did not recur during the study follow-up. The procedural complications included: blurred vision, transient sixth nerve palsy and exacerbation of chemoproptosis in two, one and two patients respectively that completely resolved in initial weeks with no recurrence. No patient worsened or developed new symptoms suggestive of a recurrent fistula during the follow-up period. One patient experienced intracranial dissection of the internal carotid artery and ischemic stroke with an unfinished procedure. The relief of early presentation was durable in long-term follow-up and the cured lesions were stable in angiographic controls. Favorable and durable outcomes could be obtained following endovascular approaches for cDAVF presenting with different ocular symptoms.

Mid- and long-term outcomes of carotid-cavernous fistula endovascular management with Onyx and n-BCA: experience of a single tertiary center

INTRODUCTION

Endovascular therapy is the preferred treatment for most carotid-cavernous fistulas (CCFs). Early reports have documented excellent initial clinical and radiographic outcomes after embolization of CCFs with Onyx or n-butyl cyanoacrylate (n-BCA), but little evidence is available about the long-term durability of this technique.

OBJECTIVE

To characterize the long-term durability of CCF liquid embolization.

METHODS

The authors retrospectively reviewed a database of 24 CCFs in 21 consecutive patients who underwent Onyx or n-BCA embolization of a CCF from 2006 to 2013 at our institution.

RESULTS

A total of 25 Onyx or n-BCA embolization procedures were attempted and 24 successfully completed during the study, resulting in complete or near-complete occlusion by the end of the study in all 24 CCFs (obliteration success, 100%). Attempted embolization in a single CCF failed initially, but was performed successfully at a later date by a different approach. None of the 24 CCFs recanalized, regrew, or required any further treatment subsequent to Onyx or n-BCA embolization throughout a mean 12.4 months of angiographic follow-up (range 1-36 months). Clinically significant complications were seen in three embolization procedures, including cranial nerve palsies (n=1), embolic infarct (n=1), and intraperitoneal hemorrhage (n=1).

CONCLUSIONS

Early evidence has indicated that endovascular embolization with Onyx is relatively safe and effective at achieving an initial angiographic cure for CCFs. Results of our series suggest that angiographic and clinical outcomes of Onyx and n-BCA embolization remain stable at mid- and long-term follow-up.

Guidelines for the use of NBCA in vascular embolization devised by the Committee of Practice Guidelines of the Japanese Society of Interventional Radiology (CGJSIR), 2012 edition

Cyanoacrylates are a group of fast-acting adhesives. They form low viscosity liquids in the monomer state and instantly polymerize to become adhesive upon contact with ionic substances. Since the 1950s, they have been used around the world for industrial and household purposes. N-butyl cyanoacrylate (NBCA) is a cyanoacrylate that is commonly used for medical care, and the closure of skin wounds with NBCA has been found to promote hemostasis. However, in Japan, the intravascular injection of NBCA is considered to be off-label use, except during the treatment of gastric varices under endoscopy. The use of NBCA in embolotherapy is considered when the target vessels cannot be cannulated superselectively, for vascular diseases that require long segments of the target vessel to be embolized, or for patients in a hypocoagulable state. NBCA-based embolotherapy can be used to treat vascular malformations, acute hemorrhaging, tumors, and venous disease. The complications associated with NBCA-based embolotherapy include tissue ischemia, hemorrhaging, systemic or local reactions, and catheter adhesion to blood vessels. NBCA is mixed with Lipiodol to make it radiopaque and to adjust its polymerization time. Since there are various technical aspects to performing NBCA-based embolotherapy safely, it should be carried out by, or with the assistance of, proficient interventional radiologists.

Two microcatheter technique for embolization of arteriovenous fistula with liquid embolic agent

Problem with embolization of arteriovenous fistula (AVF) with liquid embolic agent is its over-penetration into the veins or regurgitation to the proximal feeder without reaching the shunt point. We present a technique that controls the flow of AVF during embolization. Two microcatheter technique consists of positioning one microcatheter close to the AVF for embolization, and with another microcatheter at the proximal feeding artery to control the AVF flow by coiling. Selective angiograms obtained using a distally positioned microcatheter before and after coiling, were compared how much stagnant effect was achieved. Using two microcatheter technique, AVF occlusion was achieved with good penetration of glue to the venous side of the AVF. Its advantage is the ability to push glue into the shunt without causing over-penetration of glue or its reflux along the feeder. Two microcatheter technique was safe and effective in glue embolization of AVF and also expected to be applied with other liquid embolic agent like Onyx.

Transvenous embolization in spontaneous direct carotid-cavernous fistula in childhood

Carotid cavernous fistula (CCF) is an abnormal arteriovenous communication in the cavernous sinus. Direct CCF results from a tear in the intracavernous carotid artery. Typically, it has a high flow and usually presents with oculo-orbital venous congestive features such as exophthalmos, chemosis, and sometimes oculomotor or abducens cranial nerve palsy. Indirect CCF generally occurs spontaneously with subtle signs. We report a rare case of spontaneous direct CCF in childhood who did not have the usual history of craniofacial trauma or connective tissue disorder but presented with progressive chemosis and exophthalmos of the right eye. This report aims also to describe the safety and success of transvenous embolization with coils of the superior ophthalmic vein and cavernous sinus through the inferior petrosal sinus.