Usefulness of percutaneously injected ethylene-vinyl alcohol copolymer in conjunction with standard endovascular embolization techniques for preoperative devascularization of hypervascular head and neck tumors: technique, initial experience, and correlation with surgical observations

Assessing the safety and efficacy of EVOH Pre-Embolization in head and neck paraganglioma tumors: A comprehensive analysis of current literature

BACKGROUND

Head and Neck Paragangliomas are characterized by having a rich blood supply. Presurgical embolization with Onyx as a neoadjuvant treatment is not a consensus regarding its efficacy and safety. Our study aimed to answer this matter through a single-arm meta-analysis.

METHODS

We systematically reviewed 4 databases. Sixteen studies were described and suitable papers were selected for meta-analysis of estimated intraoperative blood loss (EBL), percentage of tumor devascularization, and complications associated with embolization.

RESULTS

The study identified 198 patients with 203 tumors, aged between 8 and 70 years. Commonly reported symptoms included neck mass perception and cranial nerve impairment. Carotid Body Tumors were most prevalent (127, 62.5 %), followed by jugular (48, 23.6 %), or vagal (29, 14.2 %) tumors. Eight studies reported estimated intraoperative blood loss (EBL) averaging 261.89 ml (95 %CI: 128.96 to 394.81 ml). In an analysis of 9 studies, 99 % (95 %CI: 96 to 100 %) achieved 70 % or more devascularization, and 79 % (95 %CI: 58 to 100 %) achieved 90 % or more devascularization. Complications from endovascular procedures were observed in 3 % (95 %CI: 0 to 8 %) of 96 patients across 10 studies, including 4 facial nerve deficits. Eighteen postoperative neurological deficits were reported across 15 articles.

CONCLUSION

Despite acknowledged limitations, with refined indications, EVOH, especially Onyx embolization may significantly bolster patient safety, decreasing EBL and easing surgical resection. Further research with larger studies will refine criteria, optimize techniques, and improve patient care and treatment outcomes in the management of head and neck paragangliomas.

Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare outcomes of juvenile nasopharyngeal angiofibroma (JNA) resection between embolized and non-embolized cohorts, and between transarterial embolization (TAE) and direct puncture embolization (DPE).

DATA SOURCES

Per PRISMA guidelines, PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched for publications prior to or in 2021.

MATERIALS AND METHODS

Original English manuscripts investigating the resection of JNA with and without preoperative embolization were included. Embolization type, recurrence rate, complication rates, blood loss, and transfusions were extracted. Risk of bias was assessed by the Risk of Bias in Non-randomized Studies-of Interventions method.

RESULTS

There were 61 studies with 917 patients included. Preoperative embolization was performed in 79.3% of patients. Of those embolized, 75.8% (N = 551) underwent TAE and 15.8% (N = 115) underwent DPE. JNA recurrence in embolized patients was lower than in non-embolized patients (9.3% vs. 14.4%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.35, 1.06). DPE resulted in lower rates of disease recurrence (0% vs. 9.5%; OR: 0.066, 95% CI: 0.016, 0.272) and complications (1.8% vs. 21.9%; OR: 0.07, 95% CI: 0.02, 0.3) than TAE. A random effects Bayesian model was performed to analyze the difference in mean blood loss in 6 studies that included both embolized and non-embolized patients. This analysis showed a mean reduction in blood loss of 798 mL in the embolized group.

CONCLUSIONS

We found embolization decreases blood loss in JNA resection. DPE led to improved recurrence and complication rates when compared to TAE, but future prospective studies are needed to further evaluate which embolization technique can optimize outcomes in JNA.

LEVEL OF EVIDENCE

NA Laryngoscope, 2023.

Orbital Venous Malformation Excision after Transcaruncular Embolization with Onyx

Orbital venous malformations are low-flow lesions resulting from vascular dysgenesis during development. Patients may present with vision loss, proptosis accentuated by Valsalva, and/or painful spontaneous thrombosis. The preferred treatment for symptomatic lesions is embolization combined with excision. A 34-year-old male presented to our institution from an outside emergency department with a diagnosis of presumed idiopathic orbital inflammation. For the prior month, he had been experiencing left orbital pressure, subjective eye bulging, and both diplopia and blurry vision when in peripheral gaze or when bending over. Despite initial improvement with steroids, his symptoms recurred with tapering. Visual acuity was reduced to 20/25, but pupils and motility remained normal. Biopsy demonstrated a vascular lesion characterized by fibroadipose tissue with histologically unremarkable blood vessels, and cerebral arteriography showed no high-flow components. A diagnosis of orbital venous malformation was made. He then underwent intraoperative angiography and Onyx embolization followed by excision via a transcaruncular approach. Two prior reports have described the use of Onyx in venolymphatic malformations. This report highlights a detailed approach to defining flow characteristics pre- and intraoperatively and expands upon our understanding of the use of Onyx for such cases.

Head and Neck Paragangliomas in the Czech Republic: Management at the Otorhinolaryngology Department

Head and neck paragangliomas (HNPGLs) are rare neuroendocrine tumors, comprising only 3% of all head and neck tumors. Early diagnosis forms an integral part of the management of these tumors. The two main aims of any treatment approach are long-term tumor control and minimal cranial nerve morbidity. The scope of this article is to present our case series of HNPGLs to stress most important clinical aspects of their presentation as well as critical issues of their complex management. Thirty patients with suspected HNPGLs were referred to our otorhinolaryngology clinic for surgical consultation between 2016–2020. We assessed the demographical pattern, clinicoradiological correlation, as well as type and outcome of treatment. A total of 42 non-secretory tumors were diagnosed—16.7% were incidental findings and 97% patients had benign tumors. Six patients had multiple tumors. Jugular paragangliomas were the most commonly treated tumors. Tumor control was achieved in nearly 96% of operated patients with minimal cranial nerve morbidity. Surgery is curative in most cases and should be considered as frontline treatment modality in experienced hands for younger patients, hereditary and secretory tumors. Cranial nerve dysfunction associated with tumor encasement is a negative prognostic factor for both surgery and radiotherapy. Multifocal tumors and metastasis are difficult to treat, even with early detection using genetic analysis. Detecting malignancy in HNPGLs is challenging due to the lack of histomorphological criteria; therefore, limited lymph node dissection should be considered, even in the absence of clinical and radiological signs of metastasis in carotid body, vagal, and jugular paragangliomas.

Single-Center Experiences of Preoperative Juvenile Nasal Angiofibroma Embolization With Gelfoam, Reducing Financial Burden on Patients in Developing Country

Introduction

Juvenile nasal angiofibroma (JNA) is a highly vascular tumor of the nasopharynx. Endovascular embolization followed by surgery is the treatment of choice. This study aimed to determine that single catheter technique with Gelfoam is an effective and safe technique for embolization to reduce the financial burden on patients in a developing country.

Materials and methods

We retrospectively reviewed the imaging, surgical, and histopathological records of 108 patients who underwent preoperative endovascular tumor embolization followed by surgical resection between March 2017 and March 2021.

Results

After embolization no major complication was observed in any patient. Complete devascularization of tumor was done in 87.8%. Intraoperative blood loss resulting in transfusion was almost the same as with other embolization techniques.

Conclusion

Single catheter with Gelfoam is a cost-effective and safe technique for JNA embolization.

Safety and Effectiveness of Ethylene Vinyl Alcohol Copolymer Embolization of Peripheral High-Flow Arteriovenous Malformations: Results of a Prospective Study

PURPOSE

To prospectively evaluate the efficacy and safety of a new ethylene vinyl alcohol (EVOH) copolymer-based embolic agent in the treatment of symptomatic peripheral arteriovenous malformations (AVMs).

MATERIALS AND METHODS

This prospective single-center study evaluated EVOH embolization with 3 different formulations of EVOH (Squid Peri 12 cP, 18 cP, and 34 cP; BALT Germany GmbH, Düsseldorf, Germany) in patients with symptomatic AVMs. Between April 2018 and October 2019, 36 embolization procedures in 21 patients (3 males and 18 females; mean age, 34.7 years) were performed (inclusion criteria: symptomatic peripheral AVM, ≥14 years of age, and elective embolization). Symptoms, technical aspects (transarterial, transvenous, or percutaneous approach; plug or balloon occlusion), clinical and technical success (defined as the improvement of symptoms and complete angiographic eradication of the AVM nidus), adverse events, and short-term outcomes were assessed.

RESULTS

The mean volume of the embolic agent used per session was 3.4 mL of EVOH 34 cP (standard deviation [SD], ± 5.4), 6.2 mL ± 8.1 of EVOH 18 cP, and 4.6 mL ± 10.1 of EVOH 12 cP. Angiographic success was achieved in 18 patients (85.7%). The mean follow-up was 190 days (range, 90-538 days; median, 182 days). In the follow-up assessment, findings of magnetic resonance imaging showed that 19 patients (90.5%) had a persistent state of devascularization compared with postinterventional angiography. Amelioration or complete elimination of pain was achieved in 90.0% of the patients. One patient experienced a major adverse event; minor adverse events developed in 2 patients.

CONCLUSIONS

In this study, EVOH appeared to be a safe and effective embolic agent in peripheral AVMs and had a low rate of adverse events in a limited number of patients.

Safety and technical efficacy of pre-operative embolization of head and neck paragangliomas: A 10-year mono-centric experience and systematic review

OBJECTIVES

To retrospectively evaluate the safety and technical success of pre-operative embolization (POE) of head and neck paragangliomas (HNP) in a single-center cohort over a 10-year period, and to benchmark our results with those derived from a systematic analysis of the available literature.

METHODS

All consecutive HNP embolized between November 2010 and April 2020 were included and reviewed. In total, there were 27 HNP in 27 patients [8 (30%) males; 19 (70%) females; mean age 53 ± 16 years; range 30-86]. Embolization technique, total procedure time, dose area product (DAP), complications, rate of HNP devascularization, and technical success (i.e. ≥80% devascularization of the HNP) were recorded and analyzed. A systematic analysis on the safety and technical success of POE was then conducted according to the Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty-one (21/27; 78%) HNP were treated with an endovascular approach and 6/27 (22%) with a percutaneous or combined (endovascular/percutaneous) technique. Mean total procedure time and DAP were 108 ± 48 min (range 45-235) and 92.5 ± 61.3 Gy·cm² (range 19.9-276.0), respectively. Two (2/27; 7%) complications (one minor, one major) were observed. Mean HNP devascularization was 88 ± 15% (range 23-100) with technical success achieved in 24/27 (89%) HNP. Literature analysis revealed a pooled rate of complication and technical success of 3.8% (95% CI: 0.5-8.8%) and 79.0% (95% CI: 63.6-91.6%), respectively.

CONCLUSIONS

POE of HNP is safe and results in extensive devascularization in the majority of treated tumors.

Onyx embolization of skull base paragangliomas: a single-center experience

BACKGROUND

Skull base paragangliomas are highly vascular tumors that are often embolized before surgical resection; however, the safety and efficacy of preoperative embolization using an ethylene vinyl alcohol copolymer (Onyx; Medtronic, Dublin, Republic of Ireland) in these tumors is unknown. This retrospective cohort study evaluated patient outcomes after preoperative embolization of skull base paragangliomas using Onyx.

METHODS

We retrospectively analyzed data from all patients with skull base paragangliomas who underwent preoperative Onyx embolization at our institution (January 01, 2005-December 31, 2017). Patient, tumor, embolization, and outcomes data were extracted by reviewing inpatient and outpatient clinical and imaging records.

RESULTS

Seven patients were studied (5/7 [71%] female), 6 with glomus jugulares and 1 with a glomus vagale. The median age was 52 years, and the most common presenting symptom was cranial neuropathy (6/7 [86%]). The tumor vascular supply was from the ascending pharyngeal artery in all 7 cases (100%) with additional feeders including the occipital artery in 5 (71%); internal carotid artery in 3 (43%); middle meningeal, vertebral, and internal maxillary artery each in 2 (29%); and posterior auricular artery in 1 (14%). The median postembolization tumor devascularization was 80% (range, 64-95%). The only postembolization complication was a facial palsy in 1 patient.

CONCLUSION

Preoperative embolization with Onyx affords excellent devascularization for the majority of skull base paragangliomas, and it may facilitate resection of these hypervascular lesions. The advantages provided by Onyx with respect to penetration of intratumoral vessels must be weighed against the risk of cranial neuropathy.

Pre-operative direct puncture embolization of head and neck hypervascular tumors using SQUID 12

OBJECTIVE

The authors have evaluated their experience in pre-operative direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12, an embolic liquid agent.

METHODS

Between July 2016 and March 2019, the authors retrospectively reviewed clinical, embolization and surgical data of 11 consecutive patients with 12 hypervascular head and neck tumors who had undergone pre-operative embolization using SQUID 12. Percutaneous embolizations were performed by inserting a 19-22 Gauge needle directly into the tumor under ultrasound, fluoroscopic and/or endoscopic guidance. The hub of the needle was connected to a 15-cm DMSO-compatible extension tube, and the SQUID 12 was injected.

RESULTS

Total or near-total devascularization was achieved in 11 over 12 cases. Complete en-bloc tumor removal by surgery was achieved in all cases. Only one patient required blood transfusion. No major periprocedural adverse events were recorded.

CONCLUSIONS

Direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12 seems to be safe and effective. It may offer almost complete devascularization due to homogenous, deep penetration in the tumor, with optimal visibility of the agent throughout the percutaneous procedure. It may reduce intraoperative blood loss and the need for transfusion, thus facilitating complete surgical resection.

Preoperative transcatheter arterial embolization using a gelatin sponge for head and neck tumors

Purpose: To evaluate the usefulness of preoperative transcatheter arterial embolization using a gelatin sponge for hypervascular head and neck tumors to reduce intraoperative blood loss (IBL).　　　　 Material and methods: Nineteen patients underwent preoperative transcatheter arterial embolization for hypervascular head and neck tumors using a gelatin sponge. The technical success rate, devascularization rate, IBL, and complications were evaluated. Angiography images obtained before and after preoperative embolization were compared in all patients, and the devascularization rate was assessed from the relative reduction rate of contrast agent volumes. Results: The technical success rate was 100%. The median devascularization rate was 95% (range, 75-100%). The median period between embolization and surgical resection was one day (range, 1-12 days). The median IBL was 122 ml (range, 0-3780 ml). Blood transfusions were required in three cases, and their IBL and devascularization rates were 850, 1959, and 3780 ml, and 75%, 90%, and 80%, respectively. There was a complication of cerebral embolism in one out of 19 cases (5%). Conclusions: Preoperative transcatheter arterial embolization using a gelatin sponge was feasible and may contribute to decreasing IBL.

Impact of preoperative transarterial embolization of carotid body tumor: A single center retrospective cohort experience

OBJECTIVE

To evaluate the feasibility and efficacy of preoperative hyperselective transarterial embolization in carotid body tumor resection.

METHODS

Retrospectively analyze the clinical feature, imaging examination, treatment strategy and prognosis of 29 carotid body tumor patients from January 2006 to January 2016. According to whether to carry out the pre-operative transarterial embolization, the patients were classified into embolization group and non-embolization group. The blood loss, operative time and perioperative complications were compared between the 2 groups.

RESULTS

29 carotid body tumors were resected. The median of blood loss was 80 mL in embolization group and 200 mL in non-embolization group, the difference was statistically significant (P = 0.001). The median of operative time was 120 min in embolization group and 160 min in non-embolization group, the difference was statistically significant (P = 0.006). No death, paralysis or ectopic embolism occurred in the study population. 4 patients in embolization group and 4 in non-embolization group suffered from cranial nerve injury.

CONCLUSION

Surgical resection of carotid body tumor is safe and reliable, which is the first choice in the treatment of carotid body tumor. Preoperative transaterial hyperselective embolization can significantly reduce blood loss and shorten operative time, but it dose not decrease the incidence of cranial never injury.

Paragangliomas of the Head and Neck

Paragangliomas of the head and neck are rare vascular skull-base tumors derived from the paraganglionic system with an estimated incidence of 1:30,000 accounting for 3% of all paragangliomas. The most common paraganglioma locations of the head and neck in descending order are the carotid body, jugular, tympanic, and vagal paragangliomas. This article discusses the clinical characterics, normal anatamy, imaging findings and protocols, pathology, staging, and differential diagnosis for paragangliomas of the head and neck.

The Effects of Preoperative Embolization on Carotid Body Paraganglioma Surgery

Objective

There is no definitive consensus on the impact of preoperative embolization on carotid body paraganglioma management. The purpose of this study was to assess the effects of preoperative embolization on carotid body paraganglioma excision.

Data Sources

A systematic search was conducted without limits, and it included studies published on or before July 2013 from PubMed, CINAHL, Web of Knowledge, and the Cochrane Library. Relevant synonyms for the search terms “paraganglioma,”“carotid body tumor,” and “embolization” were applied.

Review Methods

Studies evaluating patients undergoing surgical intervention with embolization for carotid body tumors were included. Two reviewers independently assessed the titles and abstracts for inclusion and extracted the data. The guidelines set forth by the Cochrane Collaboration were followed in the process of data extraction. Data were pooled with a fixed effects model, and standardized mean difference (SMD) and 95% confidence intervals (95% CIs) are reported.

Results

A total of 22 studies (15 nonrandomized studies with a comparator, 7 single-arm studies) were included, enrolling 578 patients with 607 tumors. Patients undergoing preoperative embolization had significantly less estimated blood loss compared with those of surgical excision only (12 studies; 295 tumors; SMD: –0.52; 95% CI: –0.77, –0.28). Patients undergoing preoperative embolization had less operative time compared with that of surgical excision only (6 studies; 174 tumors; SMD: –0.46; 95% CI: –0.77, –0.14).

Conclusion

Surgical excision with preoperative embolization appears to decrease estimated blood loss and operative time when compared with that without preoperative embolization for carotid body paragangliomas.

Transarterial Onyx Embolization of an Orbital Solitary Fibrous Tumor

Solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm sometimes found in the orbit. We report a case of an aggressive orbital SFT with enlarged feeding vessels that was successfully resected immediately after transarterial embolization with Onyx (ethylene vinyl alcohol copolymer). To our knowledge, this is the first report showing the histopathology of Onyx embolization material in an orbital SFT.

[Potential and limitations of modern embolization therapy]

Correct clinical and angiographic classification of vascular anomalies, including consideration of their flow pattern (high-flow versus low-flow), is the basis of accurate indications for minimally invasive therapy modalities such as embolization. Technical advancements and miniaturization of catheter materials (including steerable microwires, flow-directed microcatheters and detachable tips) gained access for embolotherapy to lesions anywhere in the body. The aim of embolization, which is mainly indicated for therapy of high-flow arteriovenous malformations, is the complete, permanent occlusion of the lesion nidus. Nowadays, embolotherapy is performed using permanent liquid embolization agents, in multiple staged sessions. This technique reduces complications such as ischemic necrosis and peripheral nerve lesions compared to alcohol embolization. Sole occlusion of the arterial inflow by surgical resection or interventional coil application is considered obsolete. The size of the lesion and the high treatment costs limit the use of embolotherapy.

A comparison of particulate and onyx embolization in preoperative devascularization of juvenile nasopharyngeal angiofibromas

INTRODUCTION

Juvenile nasopharyngeal angiofibromas (JNAs) are hypervascular tumors that may benefit from preoperative devascularization to reduce intraoperative blood loss (IBL). The purpose of this study was to compare transarterial particulate embolization (TAPE) with the direct percutaneous embolization (DPE) technique using ethylene vinyl alcohol (Onyx, ev3, Irvine, CA) for the preoperative devascularization of a JNA.

METHODS

We retrospectively reviewed 50 consecutive JNA resections since 1995 for which preoperative embolization was either transarterial with particulate material (n = 39) or DPE (n = 11) using only Onyx. The IBL, transfusion requirements, operative time, and length of hospital admission were compared between the two groups.

RESULTS

The mean IBL was 1,348.7 ± 932.2 mL particulate group, 569.1 ± 700.7 mL Onyx group (one-tailed Student's t test p = 0.003). The mean unit of packed red blood cells was 1.56 ± 2.01 units particulate group, 0.45 ± 1.04 units Onyx group (p = 0.009). The relationship between embolization type and IBL remained significant or strongly correlated when accounting for the Fisch stage of the tumor (p = 0.010 and p = 0.056, respectively, by a multivariate least squares fit; alternately p = 0.0003 and p = 0.023, respectively, in the subset of patients with Fisch stage III tumors only). We also found that the proportion of resections for which an endoscopic approach could be used was significantly higher in the Onyx group than the particulate group (81.8 and 18.2 %; Pearson p = 0.0002), and this was also significant both in our multivariate nominal logistic fit (p < 0.001) and in the subset of patients with Fisch stage III tumors (p = 0.018).

CONCLUSION

Pre-operative DPE with Onyx of a JNA when compared to TAPE significantly decreased IBL and RBC transfusion requirement during surgical resection. The proportion of surgical resections performed from an endoscopic approach was higher in the DPE Onyx group, which may have affected the results.

Percutaneous embolization of an orbital hemangiopericytoma with Onyx facilitates its surgical excision

This is a case report on the surgical treatment of orbital hemangiopericytoma. The patient initially underwent an attempted excision of the tumor with significant hemorrhage elsewhere, which precluded its complete excision. Due to continued growth and pain, the patient underwent percutaneous embolization with Onyx-18 under fluoroscopic radiographic guidance. The patient continued to have pain, progressive enlargement of the tumor, and underwent surgical excision. The excision was noted to have minimal bleeding and was relatively easy to dissect and excise compared with the typical hemangiopericytoma. Embolization with Onyx-18 may be a useful preoperative treatment option for hemangiopericytomas and other vascular lesions of the orbit, and elsewhere.

Palliative embolization of hemorrhages in extensive head and neck tumors

Background:

A lot has changed in terms of intervention technique, indications and embolic agents since Duggan introduced embolization to management of postraumatic epistaxis in 1970.

Embolization is used in treatment of spontaneous and traumatic epistaxis, palliative tumors and vascular defects, as well as vascularized tumors and juvenile nasopharyngeal angiofibromas. The possibility of simultaneous visualization of pathology and implementation of therapy is one of its greatest advantages.

Material/Methods:

Authors analyzed the efficacy of selective embolization treatment of haemorrhage in advanced head and neck tumors. Seventy-six patients with such tumors treated at the Department of Otolaryngology in Bialystok between1999 and 2011 were examined.

Results:

Embolization of bleeding vessel within the tumor was effective (hemorrhage was stopped) in 65 patients (86%). Although the method is highly efficient, it is still associated with complications. Fourteen patients suffered from headaches that lasted for several days and six from face edema. Rebleeding was rare. Unfortunately, there was one case of hemiparesis.

Conclusions:

We conclude that superselective endovascular treatment deserves to be considered alongside standard options for the palliative or preoperative management of acute hemorrhage from advanced head and neck cancers.

Head, neck, and brain tumor embolization guidelines

Background

Management of vascular tumors of the head, neck, and brain is often complex and requires a multidisciplinary approach. Peri-operative embolization of vascular tumors may help to reduce intra-operative bleeding and operative times and have thus become an integral part of the management of these tumors. Advances in catheter and non-catheter based techniques in conjunction with the growing field of neurointerventional surgery is likely to expand the number of peri-operative embolizations performed. The goal of this article is to provide consensus reporting standards and guidelines for embolization treatment of vascular head, neck, and brain tumors.

Summary

This article was produced by a writing group comprised of members of the Society of Neurointerventional Surgery. A computerized literature search using the National Library of Medicine database (Pubmed) was conducted for relevant articles published between 1 January 1990 and 31 December 2010. The article summarizes the effectiveness and safety of peri-operative vascular tumor embolization. In addition, this document provides consensus definitions and reporting standards as well as guidelines not intended to represent the standard of care, but rather to provide uniformity in subsequent trials and studies involving embolization of vascular head and neck as well as brain tumors.

Conclusions

Peri-operative embolization of vascular head, neck, and brain tumors is an effective and safe adjuvant to surgical resection. Major complications reported in the literature are rare when these procedures are performed by operators with appropriate training and knowledge of the relevant vascular and surgical anatomy. These standards may help to standardize reporting and publication in future studies.

Preliminary experience with the percutaneous embolization of juvenile angiofibromas using only ethylene-vinyl alcohol copolymer (Onyx) for preoperative devascularization prior to surgical resection

BACKGROUND AND PURPOSE

Juvenile angiofibromas are hypervascular tumors that may benefit from preoperative devascularization to reduce intraoperative blood loss. Our purpose was to evaluate the extent of angiographic devascularization and intraoperative blood loss by using only Onyx for percutaneous juvenile angiofibroma tumor embolization.

MATERIALS AND METHODS

We reviewed the clinical records and preoperative and postoperative imaging studies of a consecutive series of 9 patients with juvenile angiofibromas who were treated with preoperative embolization with direct percutaneous injection of Onyx followed by resection from a standard open surgical or endoscopic approach.

RESULTS

Two Fisch type I, 1 Fisch type II, 5 Fisch type IIIa, and 1 Fisch type IVa tumor were treated. Complete devascularization was achieved in all cases percutaneously with only Onyx. There were no complications. The average intraoperative blood loss was 567.7 mL (range, 10-1700 mL). An average of 2.2 needles (range, 1-5 needles) was placed into the tumor. An average of 14.6 mL of Onyx (range, 2-25 mL) was injected into each tumor. Four Fisch type IIIa tumors were removed completely from only an ENE approach.

CONCLUSIONS

Presurgical direct percutaneous embolization of a juvenile angiofibroma with only EVOH before surgical resection is safe and feasible. Our preliminary experience suggests that Onyx may offer a higher degree of devascularization compared with other embolic agents. This may facilitate an easier surgical resection with lower blood loss.

Direct endoscopic intratumoral injection of Onyx for the preoperative embolization of a recurrent juvenile nasal angiofibroma

Percutaneous injection of embolization material within head and neck tumors is being described as an alternative or adjunct to transarterial embolization. Access in these reports is by computed tomography (CT) guidance, which is cumbersome given the need to transport the patient from the CT scanner to angiography suite. We describe a case of direct percutaneous onyx embolization of juvenile nasal angiofibroma following endoscopic access in the angiography suite including self-sustained onyx combustion during surgical electrocautery.

Pre-operative intracranial meningioma embolization

Pre-operative embolization is a routinely utilized therapeutic adjunct to the resection of hypervascular lesions of the head and neck. In particular, pre-operative cerebral angiography and tumor embolization has become standard practice at many centers in the management of select intracranial meningiomas. However, controversy remains regarding its specific indications and clinical utility. In this article, we examine the principles of meningioma embolization, emphasizing the indications, risks and benefits associated with its use in the pre-operative setting.

Preoperative embolization of juvenile nasopharyngeal angiofibromas: transarterial versus direct tumoral puncture

OBJECTIVE

Preoperative embolization of juvenile nasopharyngeal angiofibromas (JNA) has been shown to reduce operative times and blood loss. Although traditional transarterial (TA) embolization is commonly used, direct tumoral puncture (DTP) has also been advocated as an alternative. We report our series of JNAs embolized with Onyx and compare the two embolization techniques.

METHODS

We retrospectively reviewed all JNAs embolized with Onyx at our institution during a 20-month period. The fluoroscopy time, percent of tumor devascularization, periprocedural complications, and intraoperative blood loss were compared between the two groups.

RESULTS

A total of 10 patients with JNA underwent preoperative embolization by a TA route (n = 5) or DTP (n = 5). Mean fluoroscopy time was 50 and 39 minutes in the TA and DTP groups, respectively. The mean percent tumor devascularization in the TA group was 77% compared with 93% in the DTP group. Intraoperative estimated blood loss in tumors embolized transarterially was higher than those embolized by DTP (862 mL vs. 412 mL); however, this difference did not reach statistical significance. There were no neurological complications related to the embolization procedures in either group.

CONCLUSIONS

Embolization of JNAs with Onyx can be performed safely by either method. Direct puncture is associated with shorter embolization procedure times and results in a greater degree of tumor devascularization. Although there was a trend toward lesser blood loss in patients embolized by DTP, it did not reach statistical significance in this small series. Larger series are needed to determine whether the improved tumor penetration achieved with DTP translates into clinical benefit.