Korean J Radiol.  2019 Aug;20(8):1285-1292. 10.3348/kjr.2019.0127.

Coil-Protected Technique for Liquid Embolization in Neurovascular Malformations

• Park KY
• Kim JW
• Kim BM
• Kim DJ
• Chung J
• Jang CK
• Kim JH

• KMID: 2453078
• DOI: http://doi.org/10.3348/kjr.2019.0127

Abstract

OBJECTIVE
To evaluate the safety and efficacy of the coil-protected technique for liquid embolization in neurovascular malformations.
MATERIALS AND METHODS
Twenty-two patients who underwent coil-protected liquid embolization for symptomatic cranial (n = 13) and spinal (n = 9) arteriovenous fistula (AVF) or arteriovenous malformations (AVMs) were identified. A total of 36 target feeder vessels were embolized with N-butyl cyanoacrylate and/or Onyx (Medtronic). This technique was used to promote delivery of a sufficient amount of liquid embolic agent into the target shunt or nidus in cases where tortuous feeding arteries preclude a microcatheter wedging techniqu and/or to prevent reflux of the liquid embolic agent in cases with a short safety margin. The procedure was considered technically successful if the target lesion was sufficiently filled with liquid embolic agent without unintentional reflux. Angiographic and clinical outcomes were retrospectively evaluated.
RESULTS
Technical success was achieved for all 36 target feeders. Post-embolization angiographies revealed complete occlusion in 16 patients and near-complete and partial occlusion in three patients each. There were no treatment-related complications. Of the six patients who showed near-complete or partial occlusion, five received additional treatments: two received stereotactic radiosurgery for cerebral AVM, two underwent surgical removal of cerebral AVM, and one underwent additional embolization by direct puncture for a mandibular AVM. Finally, all patients showed complete (n = 19) or near-complete (n = 3) occlusion of the target AVF or AVM on follow-up angiographies. The presenting neurological symptoms improved completely in 15 patients (68.2%) and partially in seven patients (31.8%).
CONCLUSION
The coil-protected technique is a safe and effective method for liquid embolization, especially in patients with various neurovascular shunts or malformations who could not be successfully treated with conventional techniques.

Keyword

Arteriovenous fistula; Arteriovenous malformation; Embolization; NBCA; Onyx

MeSH Terms

Angiography
Arteries
Arteriovenous Fistula
Arteriovenous Malformations
Cyanoacrylates
Follow-Up Studies
Humans
Methods
Punctures
Radiosurgery
Retrospective Studies
Cyanoacrylates

Figure

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  Fig. 1 Illustration of coil-protected technique.A. During liquid embolization with non-wedging microcatheter tip due to arterial tortuosity, penetration of liquid embolic agent is impossible and early reflux occurs. B. Coil-protected technique makes it possible to deliver liquid embolic agent to target shunt without reflux proximal to coil mass.

• 

  Fig. 2 Findings for 69-year-old man presenting with nausea and vomiting that had aggravated over 3 months.A. Right vertebral angiogram shows dural arteriovenous fistula with engorged perimedullary draining vein at craniocervical junction. B. Fusion image obtained with dual 3-dimensional volume reconstruction shows relationship of two feeders, one from right vertebral artery (white color) and other from occipital artery (red color). Note that two feeders are connected near right vertebral artery (arrow). C. Non-subtracted angiogram obtained just before embolization. Arrows indicate tips of two microcatheters in feeding branch of right occipital artery, proximal microcatheter for coiling and distal microcatheter for injection of NBCA. Note coils placed between two catheter tips. Arrowhead indicates proximal marker of balloon catheter for protection of NBCA reflux into right vertebral artery during embolization. Short arrow indicates coil mass occluding another branch of right occipital artery, which is occluded to facilitate navigation of microcatheter into target feeding artery. D. Spot image obtained after injection of 11.5% NBCA. Arrow indicates reflux of NBCA into feeder arising from right vertebral artery, which is protected by inflated balloon. Use of inflated balloon during injection of NBCA prevents NBCA from refluxing into vertebral artery through its feeder, which joins with feeder of right occipital artery. E. Right vertebral angiogram shows complete occlusion of fistula. NBCA = N-butyl cyanoacrylate

• 

  Fig. 3 Findings for 30-year-old man presenting with exophthalmos and tinnitus.A. MR angiogram shows multiple fistulas in left orbital and left temporal regions. B. Left external angiogram in working projection shows intraosseous fistula fed by multiple feeders in left temporal bone. C. Non-subtracted spot image obtained just after injection of 12% NBCA by proximal coil-protected technique. Note refluxes to other feeders (short arrows) from fistula, which mimics phenomenon during Onyx (Medtronic) embolization. Long arrow indicates coil mass and final coil is not detached. D. Left internal carotid angiogram in working projection. Enlarged left ophthalmic artery is main feeding artery into shunt, which forms multiple venous pouches (asterisks) and then drains through superior ophthalmic vein and pterygoid plexus. E. Spot image obtained just after proximal coil-protected NBCA embolization. Coil delivery catheter is located at lacrimal branch of left ophthalmic artery (arrow). Final coil is not yet detached. F. Left common carotid angiogram shows complete occlusion of left temporal bone fistula and near-complete occlusion of left orbit fistula. G. 12-month follow-up MR angiogram shows no recurrence of fistulas in left orbit and left temporal bone. MR = magnetic resonance

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  Fig. 4 Findings for 8-year-old boy presenting with intracerebral hemorrhage from de novo arteriovenous malformation.A. Frontal angiogram shows arteriovenous malformation with intranidal aneurysm (arrow), which is rupture point. B. Non-subtracted image of angiogram obtained just after embolization. Note segment of feeding artery where coil mass is placed (arrowheads). Straight and curved arrows indicate microcatheter for coiling and microcatheter for Onyx injection, respectively. C. 26-month follow-up delayed arterial phase angiogram shows complete occlusion of arteriovenous malformation.

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