Transvenous embolization of vein of galen aneurismal malformations using the “Chapot pressure cooker” technique

2021 ◽  
pp. 159101992110669
Author(s):  
Tomoyoshi Shigematsu ◽  
Maximilian J Bazil ◽  
Stavros Matsoukas ◽  
Rene Chapot ◽  
Michelle Sorscher ◽  
...  
Keyword(s):  
Vein Of Galen ◽  
Transvenous Embolization ◽  
Newborn Period ◽  
Embolic Material ◽  
Delayed Bleeding ◽  
Distal Marker ◽  
Complete Closure ◽  
Liquid Embolic ◽  
Attractive Option ◽  
Detachment Zone

In some vein of galen aneurysmal malformation (VGAM) patients, transvenous embolization (TVE) is an attractive option, but its safety is unclear. Here we report the first two VGAM patients treated using the Chapot “pressure cooker” technique (ChPC). Methods Two patients, one 5-year-old and one 7-year-old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n-BCA for choroidal VGAMs. Results We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform TVE using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils and n-BCA are used to prevent reflux of Onyx. Conclusions In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: (1) without liquid embolic, deployed coils may not occlude the fistula entirely. (2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE.

Abstract 1122‐000045: Transvenous Embolization of Vein of Galen Aneurismal Malformations Using the “Chapot Pressure Cooker” Technique

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Maximilian J Bazil ◽  
Tomoyoshi Shigematsu ◽  
Maximilian J Bazil ◽  
Stavros Matsoukas ◽  
Johanna T Fifi ◽  
...  
Keyword(s):  
Transarterial Embolization ◽  
Arterial Supply ◽  
Vein Of Galen ◽  
Transvenous Embolization ◽  
Newborn Period ◽  
Embolic Material ◽  
First Report ◽  
Delayed Bleeding ◽  
Complete Closure ◽  
Liquid Embolic

Introduction : There are various procedural techniques described in the literature to treat VGAM: 1) transarterial embolization (TAE) via a transfemoral or transumbilical approach, 2) transfemoral or transtorcular venous coiling, and 3) the combined transarterial and transvenous “trapping” of the fistula. The transarterial technique has permitted our team to obtain total or near‐total obliteration in approximately 80% of cases; however, there is a patient population in whom the residual arterial supply is comprised of small perforators. In these patients, transvenous embolization (TVE) is an attractive option, but its safety is unclear. Here we report the first two VGAM patients treated using the Chapot “pressure cooker” technique (ChPC). Methods : Two patients, one 5‐year‐old and one 7‐year‐old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n‐BCA for choroidal VGAMs. We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform transvenous embolization using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils, and n‐BCA if necessary, are used to prevent reflux of Onyx. This forces the Onyx to occlude the vein and the most distal arterial segment. Results : Both patients had complete occlusion of the VGAM after ChPC. Conclusions : This is the first report to describe TVE to cure VGAM after multiple sessions of TAE. This is also the first report to apply ChPC to VGAM treatment. In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: 1) without liquid embolic, deployed coils may not occlude the fistula entirely. 2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE. Not only is the residual vein blocked, but also the incoming arterial supply which prevents delayed bleeding. In endovascular treatment of VGAM, TVE is feasible option once the dilated vein of Galen becomes small enough. To prevent incomplete occlusion or post‐procedural hemorrhagic complications, the use of the ChPC using DMSO liquid embolic material is a promising and necessary introduction to the neurointerventionalist’s treatment arsenal.

Transvenous embolization of dural carotid cavernous fistulas: the role of liquid embolic agents in association with coils on patient outcomes

2017 ◽  
Vol 10 (5) ◽  
pp. 461-462 ◽  
Author(s):  
Luís Henrique de Castro-Afonso ◽  
Felipe Padovani Trivelato ◽  
Marco Túlio Rezende ◽  
Alexandre Cordeiro Ulhôa ◽  
Guilherme Seizem Nakiri ◽  
...  
Keyword(s):  
Nerve Palsy ◽  
Complication Rates ◽  
Transvenous Embolization ◽  
Embolic Material ◽  
Ocular Symptoms ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Embolic Materials ◽  
Carotid Cavernous Fistulas

IntroductionTransvenous embolization is the standard treatment for dural carotid cavernous fistulas (DCCF). Although various embolic materials have been used, the best embolic material for the treatment of DCCF is still unknown.ObjectiveTo assess the safety and efficacy of different embolic materials used for the endovascular treatment of DCCF.MethodsA retrospective data analysis of a consecutive series of 62 patients presenting DCCF was performed. Clinical and radiological data from patients were assessed, and the embolic material used—coils or liquids—were compared between two groups of patients.ResultsComplete angiographic occlusion of DCCF after treatment was achieved in 83.9% of the patients (52/62). We found a higher rate of complete occlusion of DCCF when liquids were associated with coils than with coils alone (96.5% vs 71.8%, p=0.01), and no differences in complication rates or clinical outcomes were seen between the two groups. At the 6-month follow-up, we found a higher rate of improvement in ocular symptoms compared with cranial nerve palsy improvement (94.7% vs 77.7%, p=0.02). Two patients (3.2%) had treatment-related complications without clinical symptoms.ConclusionIn this study, in comparison with the use of coils alone, the association of transvenous embolization with liquid embolic agents for DCCF treatment resulted in higher rates of complete occlusion without increasing complication rates. The clinical outcome at the 6-month follow-up showed significant improvement in ocular symptoms over cranial nerve palsy regression, which was independent of the embolic agent chosen for treatment.

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 Preoperative Embolization of Cerebellar Hemangioblastomas with a Liquid Embolic Material (NBCA) by the “Plug and Push” Technique

2018 ◽  
Vol 12 (10) ◽  
pp. 475-480
Author(s):  
Nobuyuki Shimizu ◽  
Jun Suenaga ◽  
Hiromasa Abe ◽  
Kagemitsu Nagao ◽  
Yuta Arakaki ◽  
...  
Keyword(s):  
Preoperative Embolization ◽  
Embolic Material ◽  
Liquid Embolic

Management of direct carotid-cavernous sinus fistulas with the use of ethylene-vinyl alcohol (Onyx) only: preliminary results

2010 ◽  
Vol 112 (3) ◽  
pp. 595-602 ◽  
Author(s):  
Marco Zenteno ◽  
Jorge Santos-Franco ◽  
Vladimir Rodríguez-Parra ◽  
Jorge Balderrama ◽  
Yolanda Aburto-Murrieta ◽  
...  
Keyword(s):  
Case Series ◽  
Endovascular Techniques ◽  
Embolic Material ◽  
Ethylene Vinyl Alcohol ◽  
Sole Agent ◽  
Novel Approach ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Carotid Cavernous Fistulas

Object So-called direct carotid-cavernous fistulas (CCFs) are commonly treated by detachable balloons or coils to occlude the shunt while sparing the carotid artery. Liquid embolic agents have been rarely used, and in particular, to the authors' knowledge, the use of Onyx as the sole agent has never been reported in an indexed publication. Methods The authors describe a case series of 5 patients with posttraumatic CCF in whom embolization with Onyx was prospectively used as the sole strategy of management. Results Complete occlusion was obtained at the end of the procedure in 4 cases, and the lesion in the remaining patient subsequently occluded at the 6-month follow-up evaluation. Conclusions As endovascular techniques for treatment of direct CCFs continue to evolve, this novel approach with Onyx as the sole embolic material seems promising in treating these lesions.

Percutaneous Transfacial Direct Embolization of an Intraosseous Dural Arteriovenous Fistula

2013 ◽  
Vol 10 (1) ◽  
pp. E178-E182 ◽  
Author(s):  
John D. Nerva ◽  
Danial K. Hallam ◽  
Basavaraj V. Ghodke
Keyword(s):  
Arteriovenous Fistula ◽  
Image Guidance ◽  
Dural Arteriovenous Fistula ◽  
Venous Congestion ◽  
Embolic Material ◽  
Ocular Symptoms ◽  
Novel Approach ◽  
Liquid Embolic ◽  
Emissary Veins

Abstract BACKGROUND AND IMPORTANCE: An intraosseous dural arteriovenous fistula (DAVF) is a rare cerebrovascular disease. The fistulous connection occurs within intraosseous diploic or transosseous emissary veins causing dilated intraosseous vascular pouches. To the authors' knowledge, this report describes the first percutaneous transfacial direct embolization of an intraosseous DAVF. CLINICAL PRESENTATION: A man in his 50s with blue rubber bleb nevus syndrome presented with headaches, imbalance, decreased visual acuity bilaterally, and left eye proptosis and chemosis. Imaging demonstrated an extensive intraosseous DAVF with dilated intraosseous vascular pouches throughout his cranial base and intraorbital venous congestion. He underwent staged endovascular treatment with the goal to improve his ocular symptoms. Transarterial and transvenous approaches failed to provide adequate access to the intraosseous vascular pouches. A direct, percutaneous transfacial approach was used to access the pouches for embolization with coils and liquid embolic material. Postoperative angiography demonstrated successful embolization of the pouch within the left pterygoid wing, reduced opacification of the intraosseous fistula, and elimination of intraorbital venous congestion. At 9-month follow-up, the patient's headaches had resolved, and his ocular symptomatology had improved. CONCLUSION: Endovascular access to an intraosseous DAVF is limited by the size and location of the intraosseous vascular pouches. In this case, a direct transfacial approach under image guidance facilitated access and embolization, which led to an improvement in the patient's symptoms. This technique is a novel approach for DAVF management.

Abstract 1122‐000055: Parenchymal and Subarachnoid Angiogenesis in Patients with Vein of Galen Aneurysmal Malformation

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Maximilian J Bazil ◽  
Maximilian J Bazil ◽  
Johanna T Fifi ◽  
Alejandro Berenstein ◽  
Tomoyoshi Shigematsu
Keyword(s):  
Blood Flow ◽  
De Novo ◽  
Vascular Malformations ◽  
Case Reports ◽  
Repeated Treatment ◽  
Vein Of Galen ◽  
Hypoxic Environment ◽  
Liquid Embolic ◽  
Embolization Treatment ◽  
Bilateral Thalamus

Introduction : Vein of Galen Aneurysmal Malformation (VGAM) is an arteriovenous malformation that accounts for 30% of all pediatric vascular malformations. VGAMs undergo significant remodeling of hemodynamic and structural anatomy due to angiogenesis. These changes not only affect the malformation on a molecular and morphological basis, but may also lead to alterations in planned surgical procedures. It is imperative to better understand the dynamic, angiogenic environment of the cerebrovasculature in order to more effectively treat this disease. Methods : We present 36 cases of secondary angiogenesis in VGAM. We also present three case reports of angiogenesis secondary to VGAM. Results : Pre‐interventional angiogenesis was identified in 16 patients (44.4%) and post‐interventional angiogenesis in 20 patients (55.6%) following a stage of embolization therapy. The cohort of patients with pre‐interventional secondary angiogenesis was significantly older than patients with post‐interventional angiogenesis at initial angiogram (12 months ± 40.1 months vs. 4.0 months ± 5.4 months; p<0.05). Choroidal VGAMs presented with angiogenesis more frequently than Mural VGAMs (4/14 Mural vs 32/42 Choroidal; p<0.01). Angiogenesis was localized to either the left, right, or bilateral thalamus in 2 cases, to the cisternal space surrounding the VOG in 16 cases, and both in 18 cases. Conclusions : Upon identification of secondary angiogenesis, our team’s strategy is to embolize the venous component of the fistula. The ideal strategy in our practice is cannulation of the primary feeder of the malformation, as close to the fistula as possible, and injection of highly concentrated n‐BCA glue (70%‐90%) in a transarterial approach. After multiple rounds of embolization, feeders become less dilated and may be difficult to distinguish from angiogenesis. In this pattern, we use low‐concentrate nBCA (40%‐50%) from an identifiable, proximal feeder and occlude the venous component of the fistula. We identified two patterns of secondary angiogenesis: 1) pre‐interventional angiogenesis identified at the initial diagnostic angiogram, 2) de‐novo, post‐interventional angiogenesis during the staged‐embolization treatment‐course. Occasionally, we noted random bursts of angiogenesis. A combination of the hypoxic environment, inflammation, and hemodynamic alterations to the VGAM caused by liquid embolic/coiling may lead to a burst of angiogenesis that subsides after repeated treatment. We hypothesize that the immature sinuses typically associated with VGAM patients, which experience a decrease in blood flow and subsequently narrow after embolization, may contribute to turbulent blood flow. Development of parenchymal and subarachnoid angiogenesis is common during the multi‐session treatment of VGAM. It represents the response to the angiogenic stimuli released from the draining vein. This angiogenesis can be observed to regress spontaneously or mature as we continue to treat the VGAM. It is unnecessary to embolize secondary angiogenesis outright and it is our recommendation to chiefly target primary feeders of the VGAM as close to the venous component as possible.

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.

Removal of distal fragments of liquid embolic agents during arteriovenous malformation embolization using the TIGERTRIEVER 13: a technical report

2020 ◽  
Vol 12 (8) ◽  
pp. 794-797 ◽  
Author(s):  
Faith LY Ho ◽  
René Chapot
Keyword(s):  
Cerebral Artery ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Vascular Lesions ◽  
Embolic Agent ◽  
Embolic Material ◽  
Embolic Agents ◽  
Liquid Embolic ◽  
Retrograde Filling ◽  
Distal Migration

BackgroundArteriovenous malformations (AVMs) are vascular lesions that may be treated by an endovascular approach using liquid embolic agents but the control of the liquid embolic agent remains poor and a potential complication may be distal migration of embolic material. The TIGERTRIEVER 13 is a new stent retriever designed for stroke thrombectomy and has a version ideal for distal occlusions. We report our experience in the removal of embolic agent which had migrated into the distal vessels using the TIGERTRIEVER during PHIL/Onyx embolization of AVMs.Clinical presentationsThree patients with brain and spinal AVMs underwent endovascular embolization. During trans-arterial embolization of the AVM with PHIL/Onyx, retrograde filling of distal arterial feeders was followed by migration into the normal arterial branches (cortical middle cerebral artery, distal posterior cerebral artery, and anterior spinal artery). This resulted in occlusion or sluggish distal flow in these branches with potential significant neurological deficits. In all three cases, a Headway Duo microcatheter was navigated distally in the occluded vessel beyond the embolic material using a Traxcess microwire. The TIGERTRIEVER 13 was deployed with recanalization of the vessel after a single attempt. In all three patients there were no complications related to the retrieval of embolic agent.ConclusionDistal migrated embolic agents such as PHIL or Onyx can be removed from various arterial vascular territories using stent retrievers dedicated to small vessels.

Intracerebral Arteriovenous Fistulas Associated with Intraparenchymal Varix in Childhood: Case Reports

Neurosurgery ◽  
1990 ◽  
Vol 26 (1) ◽  
pp. 122-125 ◽  
Author(s):  
Stanley L. Barnwell ◽  
Samuel F. Ciricillo ◽  
Van V. Halbach ◽  
Michael S. B. Edwards ◽  
Philip H. Cogen
Keyword(s):  
Developmental Delay ◽  
Head Circumference ◽  
Clinical Symptoms ◽  
Case Reports ◽  
Endovascular Embolization ◽  
Vein Of Galen ◽  
Arteriovenous Fistulas ◽  
Complete Closure ◽  
Venous Varix

Abstract This report describes three children, each of whom developed an unusual malformation consisting of one or more intracerebral arteriovenous fistulas and a large intraparenchymal venous varix. Their clinical symptoms were similar to those produced by aneurysms of the vein of Galen: increasing head circumference, seizures, hemorrhage, and developmental delay. We treated each child with endovascular embolization and/or surgery and obtained complete closure of all fistulas without mortality. (Neurosurgery 26:122-125, 1990)

Sign in / Sign up

Export Citation Format

Share Document