Interventional embolization of giant thoracic tumors before surgical resection

Background Preoperative embolization of tumors is a well-established procedure that has been successfully applied in various clinical situations. Preoperative embolization can reduce the vascularity of tumors resulting in a clearer operative field, less difficult dissection, decreased blood loss, and, in some cases, a decrease in tumor size. However, few studies have been conducted regarding the preoperative embolization of giant thoracic tumors. Purpose To examine the effectiveness and safety of interventional embolization of giant thoracic tumors before surgical resection. Material and Methods A total of 14 consecutive patients with giant thoracic tumors received angiography and the feeding arteries of the tumors were embolized using polyvinyl alcohol (PVA) particles and gelatin sponges 1 day before surgical resection. The patient records were retrospectively reviewed and data regarding diagnoses, embolization, and surgical resection were recorded. Results Angiography revealed the feeding arteries of the tumors to be characterized by multiple branches and thickened vessel trunks with abnormal distal branches superimposed of the tumor shadow. Embolization was successfully without complications in all patients, and all feeding vessels of each tumor were occluded. Embolization reduced the severity of bleeding during surgery and decreased the difficulty of resection of the tumor. No intraoperative or postoperative complications occurred. Conclusion Interventional embolization is a safe and efficient method to facilitate the surgical resection of giant thoracic tumors.

Download Full-text

Preoperative Embolization of Meningiomas with N-Butyl Cyanoacrylate

Interventional Neuroradiology ◽

10.1177/159101991201800202 ◽

2012 ◽

Vol 18 (2) ◽

pp. 133-139 ◽

Cited By ~ 24

Author(s):

S. Kominami ◽

A. Watanabe ◽

M. Suzuki ◽

T. Mizunari ◽

S. Kobayashi ◽

...

Keyword(s):

Blood Loss ◽

Polyvinyl Alcohol ◽

Surgical Resection ◽

Preoperative Embolization ◽

Reduce Blood Loss ◽

First Choice ◽

Pva Particles

Meningiomas are often embolized before their surgical resection to reduce blood loss during surgery. Polyvinyl alcohol (PVA) particles have been the most frequently used material for embolization of meningiomas. We have used n-butyl cyanoacrylate (NBCA) as the first-choice material since 2001. Thirty-one meningiomas were embolized with NBCA. We report the result of embolization of meningiomas with NBCA in comparison with PVA particles.

Download Full-text

Meta-Analysis of the Effects of Preoperative Embolization on the Outcomes of Carotid Body Tumor Surgery

QJM ◽

10.1093/qjmed/hcab094.015 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mohamed Magdy Samir ◽

Tamer Abd ElWahab Abo Elezz ◽

Peter Milad Mikahail ◽

Mohamed Khaled Shafeek Bassam

Keyword(s):

Postoperative Complications ◽

Blood Loss ◽

Surgical Resection ◽

Carotid Body ◽

Surgical Outcomes ◽

Meta Analysis ◽

Operation Time ◽

Carotid Body Tumor ◽

Preoperative Embolization ◽

Tumor Surgery

ABSTRACT Background Carotid body tumors (CBTs) are situated at the bifurcation of the common carotid artery within the adventitia, and are reported to be the most common head and neck paragangliomas. Surgery is the gold standard for curative treatment of resectable CBTs and is recommended in otherwise healthy patients because of the risk of local complications related to tumor size and a small but definite risk of malignancy. Preoperative embolization has been shown to reduce potential intraoperative blood loss and provide the surgeon with greater ease and safety in excising the tumor, thus reducing the operation time and morbidity. However, other physicians have stated that although blood loss may be reduced after preoperative embolization, transfusion requirements are not affected, and that the embolization procedure adds a significant risk for stroke. Therefore, the purpose of the current study was to compare the surgical outcomes of patients undergoing CBT surgical resection with and without preoperative embolization. Aim To evaluate the need for preoperative embolization for the treatment of carotid body tumor. Methodology A meta-analysis study is done to compare the surgical outcomes of patients undergoing CBT surgical resection with and without preoperative embolization. Results Our meta-analysis for evaluation of the effects of preoperative embolization on the outcomes of carotid body tumor surgery, included (14) studies with a total number of patients (n = 477).The results of these studies showed no statistically significant difference between preoperative embolization group and non embolization group in carotid body surgery for (blood loss & operation time). Preoperative embolization did not reduce risk of postoperative complications. Conclusion Preoperative embolization shows no statistically significant reducing in blood loss and operation time, also embolization does not decrease incidence of postoperative complications. It seems that embolization should not be a routine part of carotid body tumor surgery especially with the known potential risks and complications of this procedure .

Download Full-text

Techniques of Onyx Embolization of Arteriovenous Malformation: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab061 ◽

2021 ◽

Author(s):

Kathryn M Wagner ◽

Visish M Srinivasan ◽

Peter Kan

Keyword(s):

Informed Consent ◽

Surgical Resection ◽

Arteriovenous Malformations ◽

Preoperative Embolization ◽

Great Care ◽

Endovascular Techniques ◽

Definitive Therapy ◽

Feeding Vessels ◽

Multiple Feeding ◽

Staged Treatment

Abstract Advances in endovascular techniques and tools have allowed for treatment of complex arteriovenous malformations (AVMs), which historically may have posed unacceptable risk for open surgical resection. Endovascular treatment may be employed as an adjunct to surgical resection or as definitive therapy. Improvements in embolization materials have made endovascular AVM treatment safer for patients and useful across a variety of lesions. While many techniques are employed for transarterial AVM embolization, the essential tenets apply to all procedures: (1) great care should be taken to cannulate only vessels directly supplying the lesion, and not en passage vessels, prior to injecting embolisate; (2) embolisate should travel into the nidus, but not into the draining veins; (3) embolistate reflux proximal to the microcatheter should be avoided. There are several techniques that accomplish these goals, including the plug and push method, or using a balloon to prevent embolisate reflux. We use controlled injection of liquid Onyx (Medtronic), with increasing pressure over multiple injections pushing the embolisate forward into the AVM. This is repeated in multiple feeding vessels to decrease or eliminate supply to the AVM. Here, we present a 36-yr-old female with a right parietal AVM discovered on workup of headaches. After informed consent was obtained, she underwent preoperative embolization using this technique prior to uncomplicated surgical resection. The video shows the endovascular Onyx embolization of multiple feeding vessels over staged treatment.

Download Full-text

Preoperative Embolization of Hypervascular Spinal Metastases Using Percutaneous Direct Injection with n-Butyl Cyanoacrylate

Neurosurgery ◽

10.1227/01.neu.0000223503.92392.ce ◽

2006 ◽

Vol 59 (2) ◽

pp. E431-E432 ◽

Cited By ~ 28

Author(s):

Clemens M. Schirmer ◽

Adel M. Malek ◽

Eddie S. Kwan ◽

Daniel A. Hoit ◽

Simcha J. Weller

Keyword(s):

Blood Loss ◽

Surgical Resection ◽

Direct Injection ◽

Transarterial Embolization ◽

Spinal Instrumentation ◽

Spinal Metastases ◽

Preoperative Embolization ◽

Iodized Oil ◽

Operative Blood Loss ◽

Perioperative Morbidity

Abstract OBJECTIVE: Intraoperative blood loss constitutes a major cause of perioperative morbidity in surgical decompression and reconstruction of highly vascular spinal metastatic tumors. We propose a technique for embolization of highly vascular vertebral metastases using percutaneous direct injection using n-butyl cyanoacrylate (NBCA) instead of polymethylmethacrylate to complement preoperative transarterial embolization and to minimize operative blood loss. METHODS: Five patients with renal cell carcinoma metastases to the spine (one cervical, one thoracic, and three lumbar) underwent embolization by percutaneous direct injection of the affected vertebrae with a mixture of NBCA and iodized oil to supplement transarterial embolization with polyvinyl alcohol particles and fibered platinum coils. This was achieved via a transpedicular approach in four cases and by direct vertebral body puncture in one case. RESULTS: The percutaneous NBCA direct injection procedure was technically successful in all cases and was not associated with neurological or medical complications. All patients underwent subsequent vertebrectomy and spinal instrumentation. Surgical resection was performed with lower than expected blood loss and with a subjective improvement in tumor tissue handling and dissection. CONCLUSION: The extent of tumor devascularization can be improved by supplementing transarterial embolization with NBCA direct injection to decrease operative blood loss and increase the safety of surgical resection and stabilization of highly vascular spinal metastases.

Download Full-text

Safety and Efficacy of Preoperative Embolization of Intracranial Hemangioblastomas

Operative Neurosurgery ◽

10.1227/neu.0000000000001014 ◽

2015 ◽

Vol 12 (2) ◽

pp. 135-140 ◽

Cited By ~ 1

Author(s):

Chibawanye I Ene ◽

David Xu ◽

Ryan P Morton ◽

Samuel Emerson ◽

Michael R Levitt ◽

...

Keyword(s):

Blood Loss ◽

Surgical Resection ◽

Gross Total Resection ◽

Embolic Agent ◽

Vascular Tumors ◽

Preoperative Embolization ◽

Intraoperative Blood Loss ◽

Total Resection ◽

Safety And Efficacy ◽

Embolic Agents

Abstract BACKGROUND Intracranial hemangioblastomas are highly vascular tumors that account for 1% to 2% of all central nervous system tumors. Preoperative embolization has been proposed to limit the often significant intraoperative blood loss associated with resection and potentially make the tumor more soft/necrotic and thus more amenable to gross total resection. The safety and efficacy of preoperative embolization of intracranial hemangioblastomas, however, are not well characterized. OBJECTIVE To evaluate the safety and efficacy of preoperative endovascular embolization of intracranial hemangioblastomas using a variety of embolic agents. METHODS A retrospective review of all surgically resected intracranial hemangioblastomas treated with preoperative embolization between 1999 and 2014 at 2 high-volume centers was performed. Clinical and radiographic criteria, including von Hippel-Lindau status, magnetic resonance imaging tumor characteristics, embolization-related complications, degree of angiographic devascularization, intraoperative blood loss, ability to obtain gross total resection, transfusion requirements, and operative time, were analyzed. RESULTS A total of 54 patients underwent surgery, with 24 undergoing preoperative embolization followed by surgical resection, and 30 patients undergoing surgical resection alone. Embolization-related neurological complications were seen in 6 patients (25%), including 3 hemorrhages when polyvinyl alcohol particles (P = .04) were used and 3 infarctions when liquid embolic agents were used (P = .27). Permanent neurological deficits were seen in 15%. CONCLUSION Preoperative embolization of intracranial hemangioblastomas should be performed with caution, given the potential for neurological morbidity. Further studies are needed to help guide patient and embolic agent selection.

Download Full-text

The effect of embolization with N-butyl cyanoacrylate prior to surgical resection of cerebral arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/jns.1993.78.1.0060 ◽

1993 ◽

Vol 78 (1) ◽

pp. 60-69 ◽

Cited By ~ 200

Author(s):

Jafar J. Jafar ◽

Adam J. Davis ◽

Alejandro Berenstein ◽

In Sup Choi ◽

Mark J. Kupersmith

Keyword(s):

Blood Loss ◽

Surgical Resection ◽

Surgical Complications ◽

Neurological Outcome ◽

Arteriovenous Malformations ◽

Operative Time ◽

Preoperative Embolization ◽

Intraoperative Blood Loss ◽

Cerebral Arteriovenous Malformations ◽

Significant Difference

✓ Endovascular therapy of cerebral arteriovenous malformations (AVM's) is an accepted adjunct to surgical therapy. However, the literature has not characterized the benefits or the liabilities of preoperative embolization. This series compares two groups of patients who underwent surgical resection of a cerebral AVM; one group (20 patients) received preoperative transfemoral selective embolization with N-butyl cyanoacrylate (NBCA) and the other group (13 patients) did not. In the group with preoperative embolization, the AVM's were larger (3.9 vs. 2.3 cm) and of a higher Spetzler-Martin grade (3.2 vs. 2.5) as compared to the nonembolized group. The NBCA embolization facilitated surgical resection. Arteries supplying the vascular malformation were readily distinguished from those supplying the normal brain parenchyma. Embolized vessels were compressible and easily cut with microscissors. No bleeding occurred from transected vessels. Operative time and intraoperative blood loss for the two groups were not statistically different, despite the significant differences in lesion size and grade. Endovascular complications included immediate and delayed hemorrhage (15%) and transient ischemia (5%); there were no embolization-related deaths. Postoperative complications for both groups included hemorrhage (15%), residual AVM (6%), and cerebrospinal fluid leak (3%); the mortality rate was 3%. There was no statistically significant difference in surgical complications between the embolized and nonembolized groups. Most patients (91%) in both groups had an excellent or good late neurological outcome, with no significant difference between the groups. This study concludes that preoperative NBCA embolization of AVM's makes lesions of larger size and higher grade the surgical equivalent of lesions of smaller size and lower grade by reducing operative time and intraoperative blood loss, with no statistically significant difference in surgical complications or long-term neurological outcome.

Download Full-text

Multidisciplinary management of juvenile nasopharyngeal angiofibroma

The Egyptian Journal of Neurology Psychiatry and Neurosurgery ◽

10.1186/s41983-021-00414-0 ◽

2021 ◽

Vol 57 (1) ◽

Author(s):

Walid Abouzeid ◽

Ahmed Sultan ◽

Mohamed Shadad

Keyword(s):

Blood Loss ◽

Surgical Resection ◽

Endoscopic Resection ◽

Arterial Embolization ◽

Juvenile Nasopharyngeal Angiofibroma ◽

Preoperative Embolization ◽

Imaging Evaluation ◽

Tissue Mass ◽

Nasopharyngeal Angiofibroma ◽

Male Patients

Abstract Background Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign, but the locally aggressive, vascular tumor that occurs almost exclusively in young men. Although this tumor accounts for only about 0.5% of head and neck tumors, it is by far the most common benign nasopharyngeal neoplasm. It is presented typically with epistaxis, obstructive symptoms, and chronic otomastoiditis. The examination of this tumor reveals pale reddish-blue mass. The tumor is seen on imaging as vividly augmenting soft-tissue mass centered on the sphenopalatine foramen. The treatment of choice is usually surgical resection; either open or endoscopic. Pre-operative embolization is usually done to help with hemostasis. We aim to address the efficiency and the safety of endovascular modality in JNA. Methods In the period between January 2012 to December 2017, 20 male patients with age ranging from 6 to 20 years were referred to the Endovascular Unit, at Departments of Neurosurgery in Sohag, Alexandria, and Tanta University Hospitals with JNF. Preoperative trans-arterial embolization was done, followed by endoscopic surgical resection by our ENT surgeons. All patients were subjected to clinical and radiological Imaging evaluation pre embolization, post embolization, and post endoscopic resection. All patients had clinical and radiological follow-ups for at least 1 year. Results 20 male patients with JNA underwent preoperative super-selective trans-arterial embolization. The average age at presentation was 13 years. All patients underwent successful embolization with total obliteration of vascular blush of the tumor in 15 patients, and near-total obliteration of blush in 5 patients. The dramatic effect of preoperative embolization was observed on limiting intraoperative blood loss (average 200 ml) and decreasing the time of surgery (average 2.5 h). There was no permanent morbidity or mortality related to either embolization or endoscopic resection in all patients. Conclusions Trans-arterial embolization is strongly recommended in patients with JNA, it offers a good assist to the surgeon, reduces blood loss, decreases the amount of transfusion, improves the degree of resection, reduces operative time, and decreases the incidence of recurrence.

Download Full-text

Preoperative Embolization of Hypervascular Thoracic, Lumbar, and Sacral Spinal Column Tumors: Technique and Outcomes from a Single Center

Interventional Neuroradiology ◽

10.1177/159101991301900317 ◽

2013 ◽

Vol 19 (3) ◽

pp. 377-385 ◽

Cited By ~ 37

Author(s):

Sreejit Nair ◽

Y. Pierre Gobin ◽

Lewis Z. Leng ◽

Joshua D. Marcus ◽

Mark Bilsky ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Blood Loss ◽

Thyroid Carcinoma ◽

Cell Carcinoma ◽

Renal Cell ◽

Spinal Column ◽

Poly Vinyl Alcohol ◽

Preoperative Embolization ◽

Platinum Coils ◽

Pva Particles

The existing literature on preoperative spine tumor embolization is limited in size of patient cohorts and diversity of tumor histologies. This report presents our experience with preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors in the largest series to date. We conducted a retrospective review of 228 angiograms and 188 pre-operative embolizations for tumors involving thoracic, lumbar and sacral spinal column. Tumor vascularity was evaluated with conventional spinal angiography and was graded from 0 (same as normal adjacent vertebral body) to 3 (severe tumor blush with arteriovenous shunting). Embolic materials included poly vinyl alcohol (PVA) particles and detachable platinum coils and rarely, liquid embolics. The degree of embolization was graded as complete, near-complete, or partial. Anesthesia records were reviewed to document blood loss during surgery. Renal cell carcinoma (44.2%), thyroid carcinoma (9.2%), and leiomyosarcoma (6.6%) were the most common tumors out of a total of 40 tumor histologies. Hemangiopericytoma had the highest mean vascularity (2.6) of all tumor types with at least five representative cases followed by renal cell carcinoma (2.0) and thyroid carcinoma (2.0). PVA particles were used in 100% of cases. Detachable platinum coils were used in 51.6% of cases. Complete, near-complete, and partial embolizations were achieved in 86.1%, 12.7%, and 1.2% of all cases, respectively. There were no new post-procedure neurologic deficits or other complications with long-term morbidity. The mean intra-operative blood loss for the hypervascular tumors treated with pre-operative embolization was 1745 cc. Preoperative embolization of hypervascular thoracic, lumbar, and sacral spine tumors can be performed with high success rates and a high degree of safety at high volume centers.

Download Full-text

Preoperative Onyx embolization of a giant cavernous malformation involving the dural sinuses

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.1.peds08412 ◽

2009 ◽

Vol 3 (4) ◽

pp. 302-306 ◽

Cited By ~ 3

Author(s):

Shervin R. Dashti ◽

David Fiorella ◽

Robert F. Spetzler ◽

Elisa Beres ◽

Cameron G. McDougall ◽

...

Keyword(s):

Blood Loss ◽

Transarterial Embolization ◽

Vascular Lesions ◽

Preoperative Embolization ◽

Cavernous Malformations ◽

Dural Sinuses ◽

Ideal Agent ◽

Liquid Embolic ◽

Feeding Vessels ◽

The Right

Cavernous malformations (CMs) or hemangiomas arising from within the dural sinuses are rare entities that differ from their parenchymal counterparts in that they are highly vascular lesions. While parenchymal CMs are typically angiographically occult, intrasinus malformations may have large, dural-based arterial feeding vessels that are amenable to preoperative embolization. The novel liquid embolic Onyx (ev3, Inc.) is an ideal agent for the embolization of these lesions. The authors present the first known case of a giant intrasinus CM embolized with Onyx before gross-total resection. The authors report the case of a 9-year-old boy with brief apneic episodes in whom MR imaging revealed a giant CM arising from within the right transverse and sigmoid sinuses and infiltrating the right tentorium cerebelli. At another institution, the patient had undergone 1 prior embolization and 2 unsuccessful attempts at resection. Both surgeries had been complicated by massive blood loss and were aborted. Under the authors' care, the patient underwent preoperative transarterial embolization with Onyx during which a substantial volume of the mass lesion was filled with embolisate. Subsequently, complete circumferential excision of the mass from the tentorium was accomplished with minimal intraoperative blood loss.

Download Full-text

Delayed Surgical Resection Reduces Intraoperative Blood Loss for Embolized Meningiomas

Neurosurgery ◽

10.1097/00006123-200206000-00010 ◽

2002 ◽

Vol 50 (6) ◽

pp. 1231-1237 ◽

Cited By ~ 15

Author(s):

Jay Y. Chun ◽

Michael W. McDermott ◽

Kathleen R. Lamborn ◽

Charles B. Wilson ◽

Randall Higashida ◽

...

Keyword(s):

Blood Loss ◽

Hospital Stay ◽

Surgical Resection ◽

Tumor Resection ◽

Optimal Time ◽

Preoperative Embolization ◽

Intraoperative Blood Loss ◽

Tumor Removal ◽

Duration Of Surgery ◽

Delayed Group

Abstract OBJECTIVE Embolization before surgical resection of tumors has been demonstrated to reduce intraoperative blood loss, but the optimal time that should elapse between embolization and tumor resection has not been established. We evaluated whether immediate surgical resection (≤24 h) after embolization or delayed surgical resection (>24 h) was more effective in minimizing intraoperative blood loss. METHODS We retrospectively analyzed the records for 50 patients with meningiomas who underwent preoperative embolization between 1993 and 1999. We divided the patients into two groups, i.e., those who underwent surgical resection of their meningiomas ≤24 hours after embolization and those who underwent surgery more than 24 hours after embolization. The extent of embolization, intraoperative blood loss, duration of surgery, and length of the hospital stay were compared for the two groups. Postoperative pathological specimens were examined for assessment of the extent of vascularity and necrosis caused by embolization. RESULTS Intraoperative blood loss was greater for the immediate group than for the delayed group (29% with blood loss of >1000 ml [median, 475 ml] versus 0% with blood loss of >700 ml [median, 337.5 ml];P = 0.01). There were no statistically significant differences between the groups with respect to tumor volume, extent of embolization, degree of devascularization, necrosis, duration of surgery, or length of the hospital stay. CONCLUSION Contrary to previous studies that emphasized a need for tumor removal immediately after embolization, to prevent revascularization, surgical resection of meningiomas should be delayed more than 24 hours after embolization, because there is less intraoperative blood loss.

Download Full-text