Spinal epidural arteriovenous fistula embolization with ethylene vinyl alcohol (EVOH) copolymer using the Scepter Mini dual-lumen balloon

Left unattended, spinal epidural arteriovenous fistulas (EAVFs) have a potentially severe clinical course. Embolization using ethylene vinyl alcohol (EVOH) copolymers through regular dual-lumen balloons has emerged as a potential option for the treatment of spinal arteriovenous (AV) fistulas;1–3 the main issue with this technique is the navigability of these balloons. The Scepter Mini is a low-profile, dual-lumen balloon, which may be helpful for EVOH embolization of spinal AV fistulas, as it may help to overcome the navigation drawbacks. In this technical video, we present a case of EVOH embolization of a right T6 spinal EAVF through a Scepter Mini balloon. Of note, particular attention should be paid to radiculomedullary arteries arising at the same level or at adjacent levels to avoid severe neurologic complications related to uncontrolled migration of the liquid embolic agent. Moreover, excessive use of embolic material should be avoided to prevent spinal cord compression (video 1).Video 1

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A mixture of ethylene vinyl alcohol copolymer and ethanol yielding a nonadhesive liquid embolic agent to treat cerebral arteriovenous malformations: initial clinical experience

Journal of Neurosurgery ◽

10.3171/jns.2002.97.4.0881 ◽

2002 ◽

Vol 97 (4) ◽

pp. 881-888 ◽

Cited By ~ 23

Author(s):

Jun-Ichiro Hamada ◽

Yutaka Kai ◽

Motohiro Morioka ◽

Kiyoshi Kazekawa ◽

Yasuji Ishimaru ◽

...

Keyword(s):

Clinical Experience ◽

Vinyl Alcohol ◽

Arteriovenous Malformations ◽

Embolic Agent ◽

Ethanol Mixture ◽

Content Type ◽

Ethylene Vinyl Alcohol ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Fine Print

Object. The authors report their clinical experience with their new nonadhesive liquid embolic agent, an ethylene vinyl alcohol copolymer (EVAL)/ethanol mixture, to treat arteriovenous malformations (AVMs). Methods. Between June 1995 and April 2001, 57 patients with confirmed AVMs underwent embolization of their lesions with the EVAL/ethanol mixture. In 87 procedures consisting of one to three stages, the authors embolized 185 feeding arteries to occlude as much of the AVM as possible. Repeated injections under fluoroscopic control could be performed smoothly without encountering cementing of the catheter to the vessel wall. Among the 87 embolizations undertaken in 57 patients, seven procedures (8%) in six patients produced new postembolization symptoms. Resolution of these symptoms occurred within hours or days after four of the seven procedures; permanent neurological deficits remained after the other three procedures (3.4%). Of the 57 patients, three underwent postembolization radiosurgery, and 54 underwent radical treatment with microsurgical extirpation. Histopathological examination of the 54 specimens disclosed mild inflammation within the embolized lumen without inflammatory reactions in the media or adventitia. Follow-up angiograms obtained 3 years after radiosurgery was administered showed that in all three patients treated in this fashion the nidus had completely disappeared. Conclusions. The EVAL/ethanol mixture is handled easily and appears to be an effective and safe agent for preoperative embolization of AVMs.

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Reply to: Ethylene Vinyl Alcohol Copolymer as First Hemostatic Liquid Embolic Agent for Non-variceal Upper Gastrointestinal Bleeding Patients: Pros and Cons

CardioVascular and Interventional Radiology ◽

10.1007/s00270-018-2092-z ◽

2018 ◽

Vol 42 (2) ◽

pp. 318-319

Author(s):

Marcello Andrea Tipaldi ◽

Gianluigi Orgera ◽

Miltiadis E. Krokidis ◽

Alberto Rebonato ◽

Daniele Maiettini ◽

...

Keyword(s):

Gastrointestinal Bleeding ◽

Vinyl Alcohol ◽

Upper Gastrointestinal Bleeding ◽

Embolic Agent ◽

Ethylene Vinyl Alcohol ◽

Ethylene Vinyl Alcohol Copolymer ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Pros And Cons ◽

Upper Gastrointestinal

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Embolization of spinal cord arteriovenous malformations with an ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx liquid embolic system)

Journal of Neurosurgery Spine ◽

10.3171/spi.2000.93.2.0304 ◽

2000 ◽

Vol 93 (2) ◽

pp. 304-308 ◽

Cited By ~ 4

Author(s):

Andrew J. Molyneux ◽

Stuart C. Coley

Keyword(s):

Spinal Cord ◽

Arteriovenous Malformations ◽

Embolic Agent ◽

Endovascular Management ◽

Content Type ◽

Ethylene Vinyl Alcohol ◽

Promising Agent ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Brain Avms

✓ In this paper the authors describe the first use of a new liquid embolic agent (Onyx) to treat spinal cord arteriovenous malformations (AVMs). Because its properties make it more predictable to use than currently available liquid agents, the authors believe that this material has great potential in the endovascular management of both spinal cord and brain AVMs. This very promising agent merits further clinical study.

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A nonadhesive liquid embolic agent composed of ethylene vinyl alcohol copolymer and ethanol mixture for the treatment of cerebral arteriovenous malformations: experimental study

Journal of Neurosurgery ◽

10.3171/jns.2002.97.4.0889 ◽

2002 ◽

Vol 97 (4) ◽

pp. 889-895 ◽

Cited By ~ 21

Author(s):

Jun-Ichiro Hamada ◽

Yutaka Kai ◽

Motohiro Morioka ◽

Kiyoshi Kazekawa ◽

Yasuji Ishimaru ◽

...

Keyword(s):

Renal Artery ◽

Vinyl Alcohol ◽

Arteriovenous Malformations ◽

Embolic Agent ◽

Ethanol Mixture ◽

Content Type ◽

Ethylene Vinyl Alcohol ◽

Ethylene Vinyl Alcohol Copolymer ◽

Delivery Technique ◽

Fine Print

Object. The authors have developed a mixture of ethylene vinyl alcohol copolymer (EVAL) and iopamidol, which is dissolved in ethanol, as an alternative solvent to provide a safe means of embolizing arteriovenous malformations (AVMs). Methods. A two-stage delivery technique is required to prevent premature precipitation in the catheter when using this material: the catheter is first infused with 30% ethanol and this is followed by the delivery of the EVAL—ethanol mixture. Acute angiographic changes were analyzed after superselective delivery of dimethyl sulfoxide (DMSO) and 30% ethanol into the renal artery of rabbits. Histological changes following the embolization of the renal artery achieved using the EVAL—ethanol mixture were recorded at 1 hour and at 2 and 16 weeks after the procedure. Although DMSO always produced severe, rapidly progressive vasospasm in the renal artery during a 1- to 60-minute postinfusion, 30% ethanol did not. Microscopically, the lumens of embolized vessels examined 1 hour after embolization with EVAL—ethanol appeared to be filled with EVAL sponges, leaving almost no open spaces. The space between the EVAL sponges and the inner surface of the vessels was filled with fresh thrombus. In the vessel walls of specimens examined 2 weeks after embolization there was no or a slight inflammatory reaction. Scattered in the EVAL sponges were almost equal numbers of neutrophilic granulocytes and mononuclear cells, indicative of a mild inflammatory response. In specimens examined 16 weeks postembolization, the changes noted at 2 weeks were intensified. There was no definite histopathological evidence of mural hemorrhage, perivascular extravasation of the mixture, or perivascular hemorrhage in any specimen that was examined. Conclusions. Although the degree of permanence of this embolization material is yet unknown, the mixture was easy to handle, and appeared safe and effective for AVM embolization. Its nonadhesive characteristic and its ability to be infused by repeated injections make it an attractive alternative to currently available materials. The good results obtained in this study led us to undertake a clinical trial, the results of which are contained in a companion article in this issue of the Journal of Neurosurgery.

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