Migration of Ethylene Vinyl Alcohol Co-Polymer in the Urinary Tract Successfully Managed

Selective embolization is the treatment of choice for traumatic renal pseudoaneurysm. The use of ethylene vinyl alcohol copolymer (EVOH) was recently described as an embolic agent in peripheral lesions. The aim of a good embolic agent is to: achieve rapid and effective embolization; reach and fill distal vasculature targeted for embolization; be easy to prepare and use. Moreover, it should be highly radiopaque, controllable during administration, biocompatible and cost-effective. EVOH is a non-adhesive embolic agent and its efficacy is independent from the coagulant status. The risk of non-targeted embolization should be reduced by the good radio-opacity of the embolic material that is injected under continuous fluoroscopy. Nevertheless, symptomatic EVOH migration was described. We report a unique case of embolization of a renal pseudoaneurysm and migration of EVOH in the urinary tract. Retrograde trans-urethral removal of the migrated embolic agent was successfully performed. Our case report indicates that EVOH may not be appropriate when a fistula with renal calyx is suspected, even if its migration in the urinary tract may be managed.

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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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Treatment of dural arteriovenous fistula using ethylene vinyl alcohol (Onyx) arterial embolization as the primary modality: short-term results

Journal of Neurosurgery ◽

10.3171/jns-07/12/1120 ◽

2007 ◽

Vol 107 (6) ◽

pp. 1120-1125 ◽

Cited By ~ 56

Author(s):

Andrew P. Carlson ◽

Christopher L. Taylor ◽

Howard Yonas

Keyword(s):

Arteriovenous Fistula ◽

Vinyl Alcohol ◽

Dural Arteriovenous Fistula ◽

Clinical Symptoms ◽

Arterial Embolization ◽

Primary Treatment ◽

Embolic Agent ◽

Ethylene Vinyl Alcohol ◽

Treatment Agent

Object A dural arteriovenous fistula (DAVF) typically involves meningeal feeding arteries and can cause clinical symptoms ranging from tinnitus to rupture of draining cortical or parenchymal veins. Surgical treatment may be technically demanding. Ethylene vinyl alcohol (Onyx, ev3 Neurovascular) has several properties that make it potentially useful as a primary treatment agent for DAVF. Onyx is expected to be a permanent embolic agent. It should have a decreased risk of catheter retention when compared with other permanent embolic materials. Methods The authors report a series of six patients with symptomatic DAVF who were treated initially with transarterial Onyx embolization and other endovascular techniques. Results Five patients had complete occlusion of their DAVF noted on the follow-up angiogram obtained between 2 and 4 months. One patient had residual filling via a small arterial branch that was stable on follow-up angiography. None of the patients had worsening of neurological function. One case was complicated by a retained catheter fragment. Conclusions Transarterial Onyx embolization and other endovascular methods can angiographically obliterate DAVF. In some cases, embolization allowed occlusion of multiple arterial feeding arteries from a single arterial injection. Technically, the embolization was optimized when a microcatheter position immediately adjacent to the point(s) of fistulization was achieved.

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Complex Renal Arteriovenous Malformation (AVM) Embolization using Ethylene Vinyl Alcohol (EVOH) Copolymer and a Balloon Microcatheter

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0039-1694094 ◽

2019 ◽

Vol 03 (02) ◽

pp. 134-138

Author(s):

Heather Kate Moriarty ◽

Warren Clements ◽

Tim Joseph ◽

Anoop Madan ◽

Tuan Phan

Keyword(s):

Arteriovenous Malformation ◽

Vinyl Alcohol ◽

Balloon Catheter ◽

Horseshoe Kidney ◽

Endovascular Embolization ◽

Effective Procedure ◽

Arterial Supply ◽

Embolic Material ◽

Ethylene Vinyl Alcohol ◽

Renal Arteriovenous Malformation

AbstractOccurrence of a symptomatic renal arteriovenous malformation (AVM) is rare. The authors present the case of a patient with a background of Turner's syndrome, hemophilia B, and horseshoe kidney, who presented with hematuria and was successfully treated with endovascular embolization. The use of a microballoon catheter Scepter XC (Microvention, Inc.) to safely embolize the feeding arterial supply, using ethylene vinyl alcohol (EVOH) copolymer (Onyx; Medtronic/ev3) has not, to the authors’ knowledge, previously been described for the treatment of renal AVM. This novel use of an occlusal balloon catheter is permitted by the precipitation rate of Onyx, and allowed a safe and effective procedure, reducing the risk of reflux, allowing a forward push of embolic material in a controlled manner.

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016395 ◽

2020 ◽

pp. neurintsurg-2020-016395

Author(s):

Frédéric Clarençon ◽

Eimad Shotar ◽

Arnaud Pouvelle ◽

Kevin Premat ◽

Stéphanie Lenck ◽

...

Keyword(s):

Vinyl Alcohol ◽

Cord Compression ◽

Embolic Agent ◽

Content Type ◽

Ethylene Vinyl Alcohol ◽

Arteriovenous Fistulas ◽

Low Profile ◽

Liquid Embolic Agent ◽

Av Fistulas ◽

Spinal Epidural

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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The failure of preoperative ethylene-vinyl alcohol copolymer embolization to improve outcomes in arteriovenous malformation management: case series

Journal of Neurosurgery ◽

10.3171/2012.11.jns112064 ◽

2013 ◽

Vol 118 (5) ◽

pp. 969-977 ◽

Cited By ~ 28

Author(s):

Michael Kerin Morgan ◽

Andrew Stewart Davidson ◽

Stavros Koustais ◽

Mary Simons ◽

Elizabeth Anne Ritson

Keyword(s):

Vinyl Alcohol ◽

Adverse Outcome ◽

Case Series ◽

Adverse Outcomes ◽

Selective Embolization ◽

Ethylene Vinyl Alcohol ◽

Ethylene Vinyl Alcohol Copolymer ◽

Brain Avms ◽

Second Period ◽

Grade Iii

Object Ethylene-vinyl alcohol copolymer embolization is increasingly used preoperatively in the resection of brain arteriovenous malformations (AVMs). However, the case for embolization improving the outcome of resection has not been evaluated. In this paper the authors set out to compare outcomes after surgery for brain AVMs in 2 consecutive periods of practice. In the first period, selective embolization was used without the use of ethylene-vinyl alcohol copolymer. In the second period, selective embolization with ethylene-vinyl alcohol copolymer was performed. Methods A consecutive case series (prospectively collected data) was retrospectively analyzed. Adverse outcomes were considered to be an outcome modified Rankin Scale score greater than 2 due to embolization or surgery. Results A total of 538 surgical cases were included. The percentages of adverse outcomes were as follows: 0.34% for Spetzler-Martin AVMs less than Grade III (1 of 297 cases); 5.23% (95% CI 2.64%–9.78%) for Grade III AVMs (9 of 172 cases); and 17% (95% CI 10%–28%) for AVMs greater than Grade III (12 of 69 cases). There was no improvement in outcomes from the first period to the second period. The adverse outcome for Grade III brain AVMs in the first period was 5.2% (7 of 135 cases) and in the second period (after ethylene-vinyl alcohol copolymer was introduced) it was 5.4% (2 of 37 cases). For AVMs greater than Grade III, the adverse outcome was 12% (6 of 49 cases) in the first period and 30% (6 of 20 cases) in the second period. Conclusions Outcomes for brain AVM surgery were not improved by ethylene-vinyl alcohol copolymer embolization. Preoperative embolization of high-grade AVMs with an ethylene-vinyl alcohol copolymer did not prevent those hemorrhagic complications which embolization is hypothesized to prevent based on theoretical speculations but not demonstrated in practice.

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Unilateral non-rotated left kidney with vascular and ureter variations in a cadaver: a unique case report with embryological and educational aspects

Jornal Vascular Brasileiro ◽

10.1590/1677-5449.200156 ◽

2021 ◽

Vol 20 ◽

Author(s):

Kusum Gandhi ◽

Judith Jaison ◽

Eti Mantri

Keyword(s):

Case Report ◽

Renal Transplantation ◽

Urinary Tract ◽

Left Kidney ◽

Lumbar Vertebrae ◽

Unique Case ◽

Medical Graduates ◽

Pathological Conditions ◽

Nephron Sparing ◽

Shape And Size

Abstract The kidneys and ureters are retroperitoneal structures in the upper part of the paravertebral gutters, tilted against the structures on the sides of the lowest two thoracic and upper three lumbar vertebrae, so that their anterior and posterior surfaces face antero-laterally and postero-medially, respectively. Congenital anomalies of the urinary tract are often the underlying cause of renal pathologies; 40% of these pathological conditions are due to variations in location, shape, and size of the kidney(s), calyces, ureter, or bladder. This case report describes the presence of a unilateral non-rotated left kidney with vascular and ureter variations found during routine cadaveric dissection for medical graduates. Alterations in rotation of the kidney and its relation to structures at the hilum have great clinical significance when conducting surgical procedures like partial nephrectomy, nephron sparing surgery, and renal transplantation.

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Case report: Complex internal mammary to pulmonary artery fistula as a cause of hemoptysis in tuberculosis: Diagnosis and endovascular management using ethylene vinyl alcohol copolymer (Onyx)

Indian Journal of Radiology and Imaging ◽

10.4103/0971-3026.76045 ◽

2011 ◽

Vol 21 (1) ◽

pp. 10 ◽

Cited By ~ 8

Author(s):

Chaitanya Ahuja ◽

Meghna Chadha ◽

Gregory Pierce

Keyword(s):

Case Report ◽

Pulmonary Artery ◽

Vinyl Alcohol ◽

Endovascular Management ◽

Ethylene Vinyl Alcohol ◽

Ethylene Vinyl Alcohol Copolymer ◽

Internal Mammary ◽

Tuberculosis Diagnosis ◽

Pulmonary Artery Fistula

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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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