Medical treatment of polymeric cerebral granulomatous reactions following endovascular procedures

2021 ◽  
pp. neurintsurg-2020-016806
Author(s):  
Therese Boyle ◽  
Suran L Fernando ◽  
Brendan Steinfort ◽  
Jamma Li ◽  
Martin Krause ◽  
...  
Keyword(s):  
Endovascular Procedures ◽  
Standard Of Care ◽  
Cerebrovascular Diseases ◽  
Endovascular Intervention ◽  
Vascular Territory ◽  
Embolic Material ◽  
Type Iv ◽  
Preventative Measures ◽  
Carotid Aneurysms ◽  
Hydrophilic Gel

BackgroundEndovascular procedures are standard of care for an increasing range of cerebrovascular diseases. Many endovascular devices contain plastic and are coated with a hydrophilic polymer which has been rarely described to embolize, resulting in distal granulomatous inflammatory lesions within the vascular territory.MethodsWe reviewed three cases of cerebral granulomatous reactions that occurred after endovascular intervention for internal carotid aneurysms. The patient procedure details, presentation, relevant investigations, and treatment course are described. We also provide a literature review on endovascular granulomatous reactions.ResultsThese three cases represent the largest biopsy proven series of cerebral granulomatosis following endovascular intervention. We highlight the variable clinical presentation, with two of the three cases having an unusually delayed onset of up to 4 years following the intervention. We show the characteristic histological findings of granulomatous lesions with foreign body material consistent with a type IV reaction, radiological abnormalities of enhancing lesions within the vascular territory of the intervention, and the requirement of prolonged immunosuppression for maintenance of clinical remission, with two of the three patients requiring a corticosteroid sparing agent. In comparison with the available literature, in addition to hydrophilic gel polymer, we discuss that plastic from the lining of the envoy catheter may be a source of embolic material. We also discuss the recommendations of the Food and Drug Administration and the implementation of novel biomaterials for the prevention of these reactions in the future.ConclusionsThere is a need for increased awareness of this severe complication of cerebral endovascular procedures and further longitudinal studies of its prevalence, optimal management and preventative measures.

scholarly journals Retrieval of a migrated N-butyl-2 cyanoacrylate cast using a snare-kit system during dural AVF embolization: A case report

2018 ◽  
Vol 24 (5) ◽  
pp. 571-573
Author(s):  
Ramy Ahmed ◽  
Satomi Ide ◽  
Hiro Kiyosue ◽  
Shuichi Tanoue ◽  
Shunro Matsumoto ◽  
...  
Keyword(s):  
Case Report ◽  
Arteriovenous Fistula ◽  
Dural Arteriovenous Fistula ◽  
Endovascular Procedures ◽  
Sigmoid Sinus ◽  
Embolic Material ◽  
Coagulation Profile ◽  
Liquid Embolic

N-butyl-2 cyanoacrylate (NBCA) is a liquid embolic material that is widely used in various endovascular procedures because of its permanent and rapid vascular occluding effect regardless of the coagulation profile of the patient. However, NBCA migration to unintended vessels may result in serious complications. This report describes the retrieval of a migrated NBCA cast from the transverse-sigmoid sinus during dural arteriovenous fistula embolization using a transvenous snaring technique.

scholarly journals Application of the Liquid Coil as an Embolic Material for Arteriovenous Malformations

2005 ◽  
Vol 11 (3) ◽  
pp. 287-295 ◽  
Author(s):  
A. Kurata ◽  
S. Suzuki ◽  
H. Ozawa ◽  
I. Yuzawa ◽  
M. Yamda ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Endovascular Procedures ◽  
Perfusion Pressure ◽  
Preoperative Embolization ◽  
Total Removal ◽  
Embolic Material ◽  
Advantages And Disadvantages ◽  
Eloquent Area ◽  
Vascular Channels ◽  
Reduce Risk

The purpose of this paper is to clarify advantages and disadvantages of platinum liquid coils as an embolic material for AVMs. During the last eight years, 50 endovascular procedures using liquid coils were conducted in our institute for 19 cases with AVMs, 15 of which were located in the eloquent area. All but one presented with haemorrhage, the exception demonstrating repeated ischemic symptoms. Only liquid coils were used as the embolic material to obliterate the nidus and feeders. In ten of the 15 patients with AVMs located in the eloquent area and one case rejecting surgery, liquid coil embolization was applied one to 11 times (average 3.5 times) to achieve decrease in size and this was then followed by radiosurgery. The remaining eight AVM patients underwent total removal after liquid coil embolization. No complications were encountered during the peri-embolization period. In all cases, the purpose of embolization was to diminish the size to facilitate radiosurgery and decrease bleeding during surgery. The liquid coil has advantages as a material for embolization of AVMs; it is non-toxic and bioinart material; it seldom occludes normal minute vascular channels; when it used in a nidus, it seldom to migrates in the venous direction, and it has good radio-opacity and offers good marking for surgery. Appropriate applications include preoperative embolization or pre-radiosurgical embolization of AVMs, especially when staged embolizations are performed to reduce risk of perfusion pressure breakthrough in patients which are large or located in the eloquent area.

Abstract P495: Aqua Embolic System: Evaluating the Performance of a New Liquid Embolic System Using a Swine AVM Model

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ichiro Yuki ◽  
Kousaku Ohkawa ◽  
Shiri Li ◽  
Earl Steward ◽  
Hsu Frank P.K. ◽  
...  
Keyword(s):  
Renal Artery ◽  
Organic Solvents ◽  
Hemorrhagic Stroke ◽  
Cerebrovascular Diseases ◽  
Left Renal Artery ◽  
Embolic Material ◽  
Injection Speed ◽  
Rete Mirabile ◽  
Brain Avm ◽  
Liquid Embolic

Introduction: Liquid embolic material (LEM) plays an essential role in the treatment of hemorrhagic stroke caused by vascular malformation such as arteriovenous malformations (AVMs). However, currently available non-adhesive LEMs has the problem of catheter entrapment, and also known to have cytotoxicity due to the organic solvents such as Dimethyl Sulfoxide (DMSO). Aqua Embolic System (AES) is a new liquid embolic material, which is mainly composed of multiple polysaccharides. AES, when injected via a microcatheter, immediately forms a solid and elastic hydrogel cast upon exposure to Ca2+ in the bloodstream. The use of organic solvents, e.g., DMSO, is not required. The performance of AES was evaluated using an established AVM model utilizing swine rete-mirabile. Methods: Under general anesthesia, the left ascending pharyngeal artery (APA) of Yorkshire swine (40 kg) was catheterized using a microcatheter (ID:0.013 inches), and AES was slowly injected into the rete-mirabile under fluoroscopy. The following parameters were assessed to evaluate the embolization performance of the AES; 1) the amount of AES required for the complete occlusion of the feeding artery, 2) injection speed, 3) radiopacity during the deployment, and 4) incidence of catheter entrapment after the injection. The same evaluation was performed on the contralateral rete-mirabile and the left renal artery as well. Results: 12 arteries in 4 swine were treated, and all arteries were completely occluded without technical complications. The injected materials immediately formed AES cast in all vessels, followed by the reflux over the tip of the microcatheter. All catheters were withdrawn without any sign of catheter entrapment. The AES mixed with tantalum based contrasts medium showed sufficient radiopacity under fluoroscopy. With the injection speed of 0.02ml/sec, the average volume required was 0.85mL for the APA and 2.9mL for the renal artery. No increased thrombogenicity or vasospasm near the treated lesion was observed during the procedure. Conclusions: AES, which is a DMSO free, non-adhesive polysaccharides-based LEM, may be used as an embolic material for the treatment of hemorrhagic stroke caused by cerebrovascular diseases, such as brain AVM.

An In Vitro Patient-Specific Biological Model of the Cerebral Artery Reproduced with a Membranous Configuration for Simulating Endovascular Intervention

2005 ◽  
Vol 17 (3) ◽  
pp. 327-334 ◽  
Author(s):  
Seiichi Ikeda ◽  
◽  
Fumihito Arai ◽  
Toshio Fukuda ◽  
Makoto Negoro ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Surgical Simulation ◽  
Medical Training ◽  
System Development ◽  
Cerebral Arteries ◽  
Cerebrovascular Diseases ◽  
Endovascular Intervention ◽  
Patient Specific ◽  
Surgical Robots

We propose an in vitro patient-specific anatomical model of the human cerebral artery and its simulation of endovascular intervention, a potent treatment modality for cerebrovascular diseases. Our proposed model reproduces the 3-dimensional vasculature lumen, using computed tomography (CT) and magnetic resonance (MR) fluoroscopic information, within a thin artery-like membranous configuration having material properties close to arterial tissue. This cerebral arterial model reproduces an exceedingly realistic surgical feel, dynamic vascular deformation and, other important aspects involving endovascular intervention, realizing a highly realistic surgical simulation. We also propose another vasculature model that reproduces the subarachnoid space around the cerebral arteries. This version simulates endovascular intervention realistically. The model is compatible with current major imaging modalities such as CT, MR, and transcranial Doppler (TDC), and should provide effective platforms for applications, such as diagnosis, surgical planning, medical training, hemodynamic analysis and medical system development and evaluation, especially surgical robots.

Carbon Dioxide As a Standard of Care for Zero Contrast Interventions: When, Why and How?

2020 ◽  
Vol 25 (44) ◽  
pp. 4662-4666 ◽  
Author(s):  
Theodosios Bisdas ◽  
Stylianos Koutsias
Keyword(s):  
Carbon Dioxide ◽  
Endovascular Procedures ◽  
Standard Of Care ◽  
Good Choice ◽  
Type Ii ◽  
Co2 Gas ◽  
Hospital Facility ◽  
Good Imaging ◽  
Critical Patients ◽  
Carbon Dioxide Co2

Background: Traditional contrast media containing iodine remain the gold standard for vessel visualization during endovascular procedures. On the other hand, their use has several side effects and implications and may cause contrast medium-induced nephropathy. Carbon dioxide (CO2) angiography is an old alternative technique used only for critical patients in order to prevent kidney damages or allergic reactions. Zero contrast procedure: The availability of automated CO2 injectors has led to an increase in the use of CO2 angiography, providing an option for zero contrast interventions, preserving patient renal function and saving costs for the hospital facility. Taking advantage of the properties of CO2 gas, it is possible to improve the performance of some complex procedures such as atherectomy and the detection of type II endoleaks after EVARs. However, a learning curve is needed to get good imaging, and learn about the qualities and limitations of the technique. Conclusions: The use of automatic delivery systems for CO2 angiography appears to be a good choice for the use of CO2 as the first imaging option. The standardization of injection protocols and the extensive use of this technique could lead to significant benefits both for the patient's prospects and health facilities.

Abstract WP10: Evaluation of a Novel Liquid Embolic Material Using a Rabbit Model: A Hydrophilic Polymer Composite Activated by the Ca2+ in the Blood

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ichiro Yuki ◽  
Kousaku Ohkawa ◽  
Frank P Hsu ◽  
Jordan C Xu ◽  
Shuichi Suzuki
Keyword(s):  
Organic Solvents ◽  
Hemorrhagic Stroke ◽  
Rabbit Model ◽  
Cerebrovascular Diseases ◽  
Embolic Material ◽  
Complete Occlusion ◽  
Injection Speed ◽  
Liquid Embolic ◽  
Technical Complication

Introduction: Liquid embolic material (LEM) plays an essential role in the treatment of hemorrhagic stroke caused by arteriovenous malformation or dural arteriovenous fistula. However, currently available non-adhesive LEMs has the problem of catheter entrapment, and also known to have a cytotoxic effect due to the organic solvents such as Dimethyl Sulfoxide (DMSO). The New Generation Liquid Embolic Material (NGLEM) is a clear liquid that immediately forms a solid hydrogel cast upon exposure to Ca2+ in the bloodstream, and organic solvents are not required (Figure1). The performance of this new liquid embolic material was evaluated using an in vivo experimental model using rabbit. Methods: Under general anesthesia, a renal artery of New Zealand rabbit (4.5-5.0kg) was catheterized under fluoroscopy using a microcatheter, and NGLEM was injected into the artery. Following factors were assessed; 1) the amount of LEM required for the complete occlusion, 2) injection speed, 3) duration of the injection, 4) radiopacity during the deployment and 5) incidence of catheter entrapment after the injection. Results: Five renal arteries in five rabbits were treated, and all arteries were completely occluded without technical complication. The injected materials immediately formed LEM cast in all vessels followed by the reflux over the microcatheter. All catheters were withdrawn without any sign of catheter entrapment. The NGLEM mixed with both iodine-based (3 animals) and tantalum based (2 animals) contrasts medium showed sufficient radiopacity under fluoroscopy. With the injection speed of 0.02ml/sec, the average volume required was 0.68ml. Average time for the complete occlusion was 237 seconds. No increased thrombogenicity or vasospasm near the treated lesion was observed during the procedure. Conclusions: NGLEM, which is a DMSO free, non-adhesive bio-polymer may be used as an embolic material for the treatment of hemorrhagic stroke caused by cerebrovascular diseases.

scholarly journals Neurosurgery in paediatric strokes

2020 ◽  
Vol 35 (1) ◽  
Author(s):  
S. Ganapathy ◽  
P. Pandey
Keyword(s):  
Neuronal Plasticity ◽  
Endovascular Procedures ◽  
Endovascular Intervention ◽  
Morbidity And Mortality ◽  
Review Of The Literature ◽  
Mortality Statistics ◽  
Vascular Volume ◽  
Paediatric Neurosurgery ◽  
Constant Change ◽  
The Difference

Abstract Paediatric strokes are a different entity owing to the difference in pathological entity causing the stroke as well as difficulty in treatment and management due to the presence of a growing brain and small vascular volume making surgery and endovascular intervention dangerous. Yet, the high neuronal plasticity coupled with unique surgical and endovascular procedures makes surgery in these conditions rewarding with improving morbidity and mortality statistics. The field is young and dynamic leading to constant change and updating. We attempt to review the current recommendations with our own experience in paediatric neurosurgery for paediatric strokes and present an overview of common conditions causing paediatric strokes. A brief review of the literature is also supplied for reference.

Evaluation of Endovascular Intervention for Tracheo-Innominate Artery Fistula: A Systematic Review

2021 ◽  
pp. 153857442098062
Author(s):  
Thomas J. O’Malley ◽  
Andrew M. Jordan ◽  
Kyle W. Prochno ◽  
Abhiraj Saxena ◽  
Elizabeth J. Maynes ◽  
...  
Keyword(s):  
Systematic Review ◽  
Endovascular Treatment ◽  
Innominate Artery ◽  
Standard Of Care ◽  
Hospital Length ◽  
Covered Stent ◽  
Endovascular Intervention ◽  
Hospital Length Of Stay ◽  
Recurrent Bleeding ◽  
Endovascular Interventions

Background: While the standard of care for suspected tracheo-innominate artery fistula (TIF) necessitates sternotomy, perioperative mortality remains high. Endovascular interventions have been attempted, but reports have been anecdotal. The aim of this systematic review was to evaluate the outcomes of endovascular management of TIF by pooling the existing evidence. Methods: An electronic database search of Ovid MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Controlled Trials Register was performed to identify all studies examining endovascular treatment of TIF. Patients greater than 14 years of age who underwent endovascular intervention for TIF were included. 25 studies consisting of 27 patients met the inclusion criteria. Results: 48.1% (13/27) of patients were male and median age was 39.0 [IQR 16.0, 47.5] years. Tracheostomy was present in 96.3% (26/27) of cases. Median duration from tracheostomy to TIF presentation was 2.2 months [0.5, 42.5]. On presentation, 84.6% (22/26) had tracheal hemorrhage, and 22.8% (6/27) were hemodynamically unstable. 96.3% (26/27) underwent covered stent graft placement while 1 patient (3.8%) had coil embolization. 18.5% (5/27) of patients required repeat endovascular intervention for recurrent bleeding, while 11.1% (3/27) required rescue sternotomy. Median hospital length of stay was 30 days [16.0, 46.5], and overall mortality was 29.6% (8/27) with a median follow-up time of 5 months [1.2, 11.5]. Conclusion: While uncommon, endovascular treatment of TIF may be a feasible alternative to sternotomy. The approach may be useful in those who are unable to undergo surgery or are likely to have adhesions from prior chest operations.

scholarly journals Hemostasis After Brachial Artery Access With the MynxGrip Device: A Case Report

2018 ◽  
Vol 12 ◽  
pp. 117954681875929 ◽  
Author(s):  
Arturo Giordano ◽  
Stefano Messina ◽  
Gennaro Maresca ◽  
Giuseppe Biondi-Zoccai
Keyword(s):  
Case Report ◽  
Iliac Artery ◽  
Brachial Artery ◽  
Endovascular Procedures ◽  
Standard Of Care ◽  
Clinical Vignette ◽  
Closure Device ◽  
Manual Compression ◽  
Alternative Means ◽  
Limited Spectrum

Purpose: Brachial access is occasionally used for endovascular procedures when other more established or safer ones (eg, femoral or radial) are contraindicated. Although manual compression is the standard of care after brachial arteriotomy, suboptimal compression may lead to bleeding or thrombosis. Arteriotomy closure devices have thus been proposed as an alternative means to achieve hemostasis after brachial arteriotomy. Yet, there is a paucity of evidence and a limited spectrum of devices suitable for brachial arteriotomy closure. We present the use of the MynxGrip closure device after brachial arteriotomy. Case: A 70-year-old gentleman underwent brachial arteriotomy followed by iliac artery stenting with a 7F compatible device. Hemostasis was then achieved with the MynxGrip device, uneventfully. Conclusions: This clinical vignette highlights the feasibility and safety of brachial use of the MynxGrip device in experienced hands, suggesting that it can represent a useful adjunct to the armamentarium of the endovascular specialist.

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