scholarly journals Glue, Onyx, Squid or PHIL? Liquid Embolic Agents for the Embolization of Cerebral Arteriovenous Malformations and Dural Arteriovenous Fistulas

2021 ◽  
Author(s):  
Dominik F. Vollherbst ◽  
René Chapot ◽  
Martin Bendszus ◽  
Markus A. Möhlenbruch
Keyword(s):  
Arteriovenous Malformations ◽  
Vascular Malformations ◽  
Endovascular Embolization ◽  
Embolic Agent ◽  
Cerebral Arteriovenous Malformations ◽  
Arteriovenous Fistulas ◽  
Advantages And Disadvantages ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Dural Arteriovenous Fistulas

Abstract Background Endovascular embolization is an effective treatment option for cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs). A variety of liquid embolic agents have been and are currently used for embolization of AVMs and DAVFs. Knowledge of the special properties of the agent which is used is crucial for an effective and safe embolization procedure. Material and Methods This article describes the properties and indications of the liquid embolic agents which are currently available: cyanoacrylates (also called glues), and the copolymers Onyx, Squid and PHIL, as well as their respective subtypes. Results Cyanoacrylates were the predominantly used agents in the 1980s and 1990s. They are currently still used in specific situations, for example for the occlusion of macro-shunts, for the pressure cooker technique or in cases in which microcatheters are used that are not compatible with dimethyl-sulfoxide. The first broadly used copolymer-based embolic agent Onyx benefits from a large amount of available experience and data, which demonstrated its safety and efficacy in the treatment of cerebral vascular malformations, while its drawbacks include temporary loss of visibility during longer injections and artifacts in cross-sectional imaging. The more recently introduced agents Squid and PHIL aim to overcome these shortcomings and to improve the success rate of endovascular embolization. Novelties of these newer agents with potential advantages include extra-low viscosity versions, more stable visibility, and a lower degree of imaging artifacts. Conclusion All the available liquid embolic agents feature specific potential advantages and disadvantages over each other. The choice of the most appropriate embolic agent must be made based on the specific material characteristics of the agent, related to the specific anatomical characteristics of the target pathology.

scholarly journals Endovascular management of spinal dural arteriovenous fistulas

2009 ◽  
Vol 26 (5) ◽  
pp. E15 ◽  
Author(s):  
Walavan Sivakumar ◽  
Gabriel Zada ◽  
Parham Yashar ◽  
Steven L. Giannotta ◽  
George Teitelbaum ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Vascular Malformations ◽  
Endovascular Embolization ◽  
Embolic Agent ◽  
Endovascular Management ◽  
Arteriovenous Fistulas ◽  
Spinal Vascular Malformations ◽  
Embolic Agents ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas

Object Spinal dural arteriovenous fistulas (DAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy, yet remain inefficiently diagnosed lesions. Over the last several decades, the treatment of spinal DAVFs has improved tremendously due to improvements in neuroimaging, microsurgical, and endovascular techniques. The aim of this paper was to review the existing literature regarding the clinical characteristics, classification, and endovascular management of spinal DAVFs. Methods A search of the PubMed database from the National Library of Medicine and reference lists of all relevant articles was conducted to identify all studies pertaining to spinal DAVFs, spinal dural fistulas, and spinal vascular malformations, with particular attention to endovascular management and outcomes. Results The ability to definitively treat spinal DAVFs using endovascular embolization has significantly improved over the last several decades. Overall rates of definitive embolization of spinal DAVFs have ranged between 25 and 100%, depending in part on the embolic agent used and the use of variable stiffness microcatheters. The majority of recent studies in which N-butyl cyanoacrylate or other liquid embolic agents were used have reported success rates of 70–90%. Surgical treatment remains the definitive option in cases of failed embolization, repeated recanalization, or lesions not amenable to embolization. Clinical outcomes have been comparable to surgical treatment when the fistula and draining vein remain persistently occluded. Improvements in gait and motor function are more likely following successful treatment, whereas micturition symptoms are less likely to improve. Conclusions Endovascular embolization is an increasingly effective therapy in the treatment of spinal DAVFs, and can be used as a definitive intervention in the majority of patients that undergo modern endovascular intervention. A multidisciplinary approach to the treatment of these lesions is required, as surgery is required for refractory cases or those not amenable to embolization. Newer embolic agents, such as Onyx, hold significant promise for future therapy, yet long-term follow-up studies are required.

scholarly journals Initial experience with precipitating hydrophobic injectable liquid in cerebral arteriovenous malformations

2018 ◽  
Vol 25 (1) ◽  
pp. 58-65 ◽  
Author(s):  
Stanimir S Sirakov ◽  
Alexander Sirakov ◽  
Krasimir Minkin ◽  
Hristo Hristov ◽  
Kristian Ninov ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Embolic Agent ◽  
Initial Experience ◽  
Cerebral Arteriovenous Malformations ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Reported Study ◽  
Liquid Embolic Agent ◽  
Staged Treatment

Background Precipitating hydrophobic injectable liquid is a newly introduced liquid embolic agent for endovascular embolization with some technical advantages over other liquid embolic agents. We present our initial experience with precipitating hydrophobic injectable liquid in the endovascular treatment of cerebral arteriovenous malformations. Methods From October 2015 to January 2018, 27 patients harboring cerebral arteriovenous malformations underwent endovascular embolization with precipitating hydrophobic injectable liquid 25. Clinical features, angiographic results, procedural details, complications, and follow-up details were retrospectively analyzed. Results Twenty-seven patients with cerebral arteriovenous malformations were included. Total obliteration in one endovascular session was confirmed for 14/27 (52%) patients. Partial embolization was attained in 13 patients (48%) in whom staged treatment with following radiosurgery or surgery was planned. No mortality was recorded in this series. Complications during or after the embolization occurred in six of 27 (22.2%) patients. Conclusion In our initial experience, precipitating hydrophobic injectable liquid has acceptable clinical outcome comparable to other liquid embolic agents. Although this is the largest reported study in arteriovenous malformation treatment with precipitating hydrophobic injectable liquid, further studies are needed to validate its safety and efficacy.

Progressive Gait Dysfunction

2016 ◽  
Author(s):  
Ji Y. Chong ◽  
Michael P. Lerario
Keyword(s):  
Arteriovenous Malformations ◽  
Vascular Malformations ◽  
Endovascular Embolization ◽  
Arteriovenous Fistulas ◽  
Progressive Myelopathy ◽  
Spinal Vascular Malformations ◽  
Gait Dysfunction ◽  
Dural Arteriovenous Fistulas ◽  
Neurological Change ◽  
Spinal Arteriovenous Malformations

Spinal vascular malformations are rare, with dural arteriovenous fistulas (AVFs) accounting for the majority of the pathology. Unlike spinal arteriovenous malformations, which cause abrupt neurological change as a result of hemorrhage, spinal dural AVFs tend to result in a progressive myelopathy through venous congestion and cord edema. If diagnosed and treated early with endovascular embolization or microsurgery, some deficits may be reversible.

Curing arteriovenous malformations using embolization

2014 ◽  
Vol 37 (3) ◽  
pp. E19 ◽  
Author(s):  
Matthew B. Potts ◽  
Daniel W. Zumofen ◽  
Eytan Raz ◽  
Peter K. Nelson ◽  
Howard A. Riina
Keyword(s):  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Cerebral Arteriovenous Malformations ◽  
Curative Intent ◽  
The Past ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Diagnostic Angiography ◽  
Endovascular Technology

Endovascular embolization is typically reserved as an adjuvant therapy in the management of cerebral arteriovenous malformations (AVMs), either for preoperative devascularization or preradiosurgical volume reduction. Curative embolization plays a limited role in AVM treatment but several studies have shown that it is possible, especially with later-generation liquid embolic agents. Given the complexity of AVM anatomy and the recent controversies over the role of any intervention in AVM management, it is critical that the cerebrovascular community better define the indications of each treatment modality to provide quality AVM management. In this review, the authors evaluate the role of curative AVM embolization. Important considerations in the feasibility of curative AVM embolization include whether it can be performed reliably and safely, and whether it is a durable cure. Studies over the past 20 years have begun to define the anatomical factors that are amenable to complete endovascular occlusion, including size, feeding artery anatomy, AVM morphology, and endovascular accessibility. More recent studies have shown that highly selected patients with AVMs can be treated with curative intent, leading to occlusion rates as high as 100% of such prospectively identified lesions with minimal morbidity. Advances in endovascular technology and techniques that support the efficacy and safety of curative embolization are discussed, as is the importance of superselective diagnostic angiography. Finally, the durability of curative embolization is analyzed. Overall, while still unproven, endovascular embolization has the potential to be a safe, effective, and durable curative treatment for select AVMs, broadening the armamentarium with which one can treat this disease.

Preliminary experience with the liquid embolic material agent PHIL (Precipitating Hydrophobic Injectable Liquid) in treating cranial and spinal dural arteriovenous fistulas: technical note

2015 ◽  
Vol 8 (6) ◽  
pp. 596-602 ◽  
Author(s):  
Joe J Leyon ◽  
Swarupsinh Chavda ◽  
Allan Thomas ◽  
Saleh Lamin
Keyword(s):  
Interventional Neuroradiology ◽  
Technical Note ◽  
Embolic Agent ◽  
Embolic Material ◽  
Arteriovenous Fistulas ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Dural Arteriovenous Fistulas ◽  
Fluoroscopic Time ◽  
Liquid Embolic Agent

BackgroundLiquid embolic agents are the preferred embolic material in endovascular treatment of pial and brain arteriovenous malformations and dural arteriovenous fistulas (DAVFs). There is little choice available in interventional neuroradiology practice other than two of the most commonly used liquid embolic agents—n-butyl cyanoacrylate and the Onyx liquid embolic system (ev3 Neurovascular, Irvine, California, USA). PHIL (Precipitating Hydrophobic Injectable Liquid) (Microvention, Inc California, USA) is a new liquid embolic agent, CE marked and available for clinical use in Europe.ObjectiveTo present our preliminary experience using PHIL in treating cranial and spinal DAVFs.MethodsBetween September 2014 and January 2015, eight patients, with five cranial DAVFs and three spinal DAVFs were treated with PHIL as the sole embolic agent used with intent to cure. Clinical presentation, location of DAVF, Borden type, fluoroscopic time, radiation dose, procedural time, injecting microcatheter used, volume of PHIL injected, complications, immediate angiographic data, premorbid and discharge modified Rankin Scale score, and any neurologic deficits were included in the analysis.ResultsSeven patients were successfully treated with complete angiographic exclusion of the fistula in a single sitting. Treatment failed in one patient where only suboptimal microcatheter positioning could be achieved and PHIL failed to penetrate the fistula's nidus. Venous penetration was achieved in all other patients except one with a small fistula, but with adequate fistula penetration by the embolic material. No other technical complication or neurologic deterioration occurred in any of the patients.ConclusionsPHIL liquid embolic agent appears to be an excellent alternative embolic material with certain advantages compared with other available liquid embolic agents. Further studies are required to fully evaluate its safety and efficacy.

Transvenous Approach to Intracranial Arteriovenous Malformations

Neurosurgery ◽  
2015 ◽  
Vol 77 (4) ◽  
pp. 644-652 ◽  
Author(s):  
Omar Choudhri ◽  
Michael E. Ivan ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Vascular Malformations ◽  
Venous Drainage ◽  
Endovascular Embolization ◽  
Intracranial Arteriovenous Malformations ◽  
Arteriovenous Fistulas ◽  
Treatment Models ◽  
Dural Arteriovenous Fistulas ◽  
Transvenous Approach ◽  
The Brain

Abstract A compartmental conceptualization of intracranial arteriovenous malformations (AVMs) allows recognition of feeding arteries, an intervening plexiform nidus, and draining veins. AVM therapy involves eliminating the nidus, which is the source of hemorrhage, without compromising normal arterial and venous drainage of the brain. Traditional methods of AVM therapy through microsurgery and endovascular embolization involve arterial devascularization, with preservation of AVM venous drainage, until the nidus is excluded. The transvenous approach in treating vascular malformations was popularized by successful treatment models for dural arteriovenous fistulas. More recently, high-flow intracranial AVMs are being managed with transvenous endovascular approaches, although this novel technique has its challenges and perils. We review the current literature on transvenous AVM therapy and highlight its role for AVM therapy in the present day.

scholarly journals Precipitating hydrophobic injectable liquid embolization of intracranial vascular shunts: initial experience and technical note

2018 ◽  
Vol 129 (5) ◽  
pp. 1217-1222 ◽  
Author(s):  
Shriram Varadharajan ◽  
Arvinda Hanumanthapura Ramalingaiah ◽  
Jitender Saini ◽  
Arun Kumar Gupta ◽  
B. Indira Devi ◽  
...  
Keyword(s):  
Endovascular Embolization ◽  
Technical Note ◽  
Embolic Agent ◽  
Arteriovenous Fistulas ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Complete Obliteration ◽  
Liquid Embolic Agent ◽  
Pial Arteriovenous Fistula

Precipitating hydrophobic injectable liquid (PHIL) is a newly available liquid embolic agent for endovascular therapy. It is nonadhesive and composed of a biocompatible polymer dissolved in dimethyl sulfoxide solvent and bonded covalently with iodine.In this report, the authors present their preliminary experience using PHIL in the treatment of intracranial vascular shunts. Between July 2015 and December 2015, 11 patients underwent endovascular embolization using the PHIL embolic agent. Five patients had arteriovenous malformations, 4 had dural arteriovenous fistulas, 1 patient had a carotid-cavernous fistula, and 1 patient had a pial arteriovenous fistula. Clinical features, angioarchitectural characteristics, procedural details, and periprocedural complications were included in the analysis.Complete or near-complete obliteration of the nidus or fistulas was achieved in 8 of these patients. Partial embolization (approximately 80% in 2 and 30% in 1) was attained in the other 3 patients. Satisfactory venous penetration after nidal embolization was achieved in all patients. In 1 patient, the microcatheter could not be retrieved. No other major complications related to PHIL injection were noted during the procedure or periprocedural period. Clinical follow-up ranging from 8 months to 1 year showed good outcomes in all but 1 patient, who experienced an intraventricular hemorrhage 6 weeks after embolization.PHIL appears to be an effective alternative embolic material with certain advantages over other available liquid embolic agents. Further studies with adequate follow-up are required to fully evaluate its safety and efficacy.

scholarly journals Open and endovascular treatment of spinal dural arteriovenous fistulas: a 10-year experience

2017 ◽  
Vol 26 (4) ◽  
pp. 519-523 ◽  
Author(s):  
Matthew J. Koch ◽  
Christopher J. Stapleton ◽  
Pankaj K. Agarwalla ◽  
Collin Torok ◽  
John H. Shin ◽  
...  
Keyword(s):  
Vascular Malformations ◽  
Management Strategies ◽  
Case Series ◽  
Endovascular Embolization ◽  
Definitive Treatment ◽  
Type I ◽  
Arteriovenous Fistulas ◽  
Presenting Symptoms ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas

OBJECTIVE Vascular malformations of the spine represent rare clinical entities with profound neurological implications. Previously reported studies on management strategies for spinal dural arteriovenous fistulas (sDAVFs) appeared before the advent of modern liquid embolic agents. Authors of the present study review their institutional experience with endovascularly and surgically treated sDAVFs. METHODS The authors performed a retrospective, observational, single-center case series on sDAVFs treated with endovascular embolization, microsurgical occlusion, or both between 2004 and 2013. The mode, efficacy, and clinical effect of treatment were evaluated. RESULTS Forty-seven patients with spinal arteriovenous malformations were evaluated using spinal angiography, which demonstrated 34 Type I sDAVFs (thoracic 20, lumbar 12, and cervical 2). Twenty-nine of the patients (85%) were male, and the median patient age was 63.3 years. Twenty patients underwent primary endovascular embolization (16 Onyx, 4 N-butyl cyanoacrylate [NBCA]), and 14 underwent primary surgical clipping. At a mean follow-up of 36 weeks, according to angiography or MR angiography, 5 patients treated with endovascular embolization demonstrated persistent arteriovenous shunting, whereas none of the surgically treated patients showed lesion persistence (p = 0.0237). Thirty patients (88%) experienced some resolution of their presenting symptoms (embolization 17 [85%], surgery 13 [93%], p = 1.00). CONCLUSIONS Microsurgical occlusion remains the most definitive treatment modality for sDAVFs, though modern endovascular techniques remain a viable option for the initial treatment of anatomically amenable lesions. Treatment of these lesions usually results in some clinical improvement.

scholarly journals Rare association between spinal dural arteriovenous fistulas and dysraphisms: Report of two cases and review of the literature with a focus on pitfalls in diagnosis and treatment

2017 ◽  
Vol 23 (5) ◽  
pp. 458-464 ◽  
Author(s):  
Giacomo Talenti ◽  
Giovanni Vitale ◽  
Giacomo Cester ◽  
Alessandro Della Puppa ◽  
Roberto Faggin ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Vascular Malformations ◽  
Diagnosis And Treatment ◽  
Review Of The Literature ◽  
Arteriovenous Fistulas ◽  
Rare Association ◽  
Spinal Vascular Malformations ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Arteriovenous Malformations ◽  
Spinal Dural Arteriovenous Fistulas

Spinal vascular malformations are uncommon yet important spinal pathologies commonly classified in congenital and acquired lesions. Spinal lipomas consist of three subtypes: intramedullary lipomas, lipomyelo(meningo)celes and lipomas of the filum. Although the association of spinal arteriovenous malformations (AVM) with other congenital anomalies is well known, the coexistence of dural arteriovenous fistulas (AVF) and tethered spinal cord is exceptionally rare and only eight cases have been reported. We present two cases from our institution and speculate on the possible origin of such a rare but insidious association. We review the current literature with a focus on possible pitfalls in diagnosis and treatment.

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