Curative embolization of pediatric intracranial arteriovenous malformations using Onyx: the role of new embolization techniques on patient outcomes

Castro-Afonso, Luís Henrique de; Nakiri, Guilherme Seizem; Oliveira, Ricardo Santos de; Santos, M. V.; Santos, Ana Cristina dos; Machado, Hélio Rubens; Abud, Daniel Giansante

doi:10.1007/s00234-016-1666-1

Cited by 47 publications

(25 citation statements)

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“…3,6 In this series, a greater propensity for multimodality treatment was evident, with nearly 80% of patients undergoing microsurgery or radiosurgery, compared with 9% in the 2014 report by Baharvahdat et al 3 Several studies that have recently reported high angiographic cure rates using Onyx embolization to treat intracranial AVMs have primarily been based on the use of detachable-tip microcatheters. 1,6,20,29,36 Comparatively, the results from the current study also appear to be congruent with reports from some of the largest published studies on Onyx embolization of brain AVMs (Table 4). 10,11,14,17,19,21,23,[25][26][27][28]30,32,35,[37][38][39][40]…”

Section: Discussionmentioning

confidence: 76%

Use of the Apollo detachable-tip microcatheter for endovascular embolization of arteriovenous malformations and arteriovenous fistulas

Flores

See

Weiner

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Liquid embolic agents have revolutionized endovascular management of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs). Nonetheless, since 2005, the US FDA has received more than 100 reports of microcatheter breakage or entrapment related to Onyx embolization, including 9 deaths. In 2014, the Apollo detachable-tip microcatheter became the first of its kind available in the US. Since then, few reports on its safety have been published. METHODS The authors conducted a retrospective review of endovascular cases by searching the patient databases at 2 tertiary cerebrovascular centers (Barrow Neurological Institute and University of Pittsburgh Medical Center). Patients who underwent endovascular embolization of an AVM or AVF using the Apollo microcatheter were identified. Patient demographics and lesion characteristics were collected. The authors analyzed Apollo-specific endovascular variables, such as number of microcatheterizations, sessions, and pedicles embolized; microcatheter tip detachment status; obliteration rate; and endovascular- and microcatheter-related morbidity and mortality. RESULTS From July 2014 to October 2016, a total of 177 embolizations using the Apollo microcatheter were performed in 61 patients (mean age 40.3 years). The most frequent presentation was hemorrhage (22/61, 36.1%). Most lesions were AVMs (51/61, 83.6%; mean diameter 30.6 mm). The mean Spetzler-Martin grade was 2.4. Thirty-nine (76.5%) of 51 patients with AVMs underwent resection. Microcatheterization was successful in 172 pedicles. Most patients (50/61, 82%) underwent a single embolization session. The mean number of pedicles per session was 2.5 (range 1-7). Onyx-18 was used in 103 (59.9%), N-butyl cyanoacrylate (NBCA) in 44 (25.6%), and Onyx-34 in 25 (14.5%) of the 172 embolizations. In 45.9% (28/61) of the patients, lesion obliteration of 75% or greater was achieved. Tip detachment occurred in 19.2% (33/172) of microcatheters. Fifty-three (86.9%) of the 61 patients who underwent embolization with the Apollo microcatheter had good functional outcomes (modified Rankin Scale score 0-2). No unintended microcatheter fractures or related morbidity was observed. One patient died of intraprocedural complications unrelated to microcatheter selection. In the univariate analysis, microcatheter tip detachment (p = 0.12), single embolized pedicles (p = 0.12), and smaller AVM nidus diameter (p = 0.17) correlated positively with high obliteration rates (> 90%). In the multivariate analysis, microcatheter tip detachment was the only independent variable associated with high obliteration rates (OR 9.5; p = 0.03). CONCLUSIONS The use of the Apollo detachable-tip microcatheter for embolization of AVMs and AVFs is associated with high rates of successful catheterization and obliteration and low rates of morbidity and mortality. The microcatheter was retrieved in all cases, even after prolonged injections in distal branch pedicles, often with significant reflux. This study represents the largest case series on the applica...

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Section: Discussionmentioning

confidence: 76%

Use of the Apollo detachable-tip microcatheter for endovascular embolization of arteriovenous malformations and arteriovenous fistulas

Flores

See

Weiner

et al. 2019

Journal of Neurosurgery

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“…It was not clear how much of the poor outcome was related to surgical resection, embolization, or delayed hemorrhage from partially embolized AVM. On the other hand, a curative embolization with Onyx with high cure rates as recently published (van Rooij et al 2012 ; de Castro-Afonso et al 2016 ) that was associated with low morbidity and mortality (< 10%) may serve as a good treatment option. A low complication rate (< 10%) is lower than the complication rate of the medical arm of the ARUBA trial (Mohr et al 2014 ).…”

Section: Discussionmentioning

confidence: 92%

“…In the current study, complete occlusion was achieved in 9 patients (42.9%), this cure rate is similar to the previously quieted figures, and this high cure rate could be explained by the prior intention to completely occlude the lesion whenever possible, the use of Oynx with detachable tip catheters which permit longer injection time, and the use of staged approach. With case selection, van Rooij et al ( 2012 ) reported achievement of cure for all the selected patient (24 patients) using Onyx without morbidity or mortality; also, de Castro-Afonso et al ( 2016 ) reported (91.3%) cure rate in their selected AVM pediatric patients (23 patients) with (13%, 3 patients) procedure-related complications, yet without significant morbidity or mortality.…”

Section: Discussionmentioning

confidence: 99%

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Cerebral arteriovenous malformations in the era of embolization for angiographic cure: a single-center experience in Egypt

Elewa

2018

Egypt J Neurol Psychiatry Neurosurg

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BackgroundEmbolization for cerebral arteriovenous malformations (AVMs) has evolved in the last decade with evolution in both equipment and material. Embolization targets have expanded to include angiographic cure.MethodsTo discuss the technical and management outcomes of our first cerebral AVM case series treated with embolization. The clinical, angiographic, treatment, and outcome variables of consecutive cerebral arteriovenous malformation cases, treated with curative embolization, between January 2011 and June 2017 in one regional center, were retrospectively analyzed.ResultsIn 21 patients, 21 AVMs were identified, and 13 patients (61.9%) were males. The mean of the age was 34.24 ± 12.99. Fifteen patients (71.4%) had a history of intracranial hemorrhage, and 10 (47.6%) patients had seizures. Sixteen patients (76.2%) were at grade 1 of modified Rankin Scale (mRS) at admission. The median for modal Spetzler-Martin grade was 2. The average number of arterial feeders was 3. Direct arteriovenous fistulas were found in 4 cases (19.0%). Venous aneurysms were found in 4 cases (19.0%). Seventeen AVMs (80.9%) were considered high bleeding risk lesions. Forty-three embolization sessions were done. Early hemorrhage occurred in 3 sessions (7.0%). Vessel perforation occurred 1 session (2.3%). Poor outcome occurred in 1 patient that was discharged at grade 3 mRS. Angiographic cure was achieved in 9 patients (42.9%). The average size reduction was 65%.ConclusionsOnyx embolization could serve as a curative option for AVM treatment with accepted morbidity and mortality.

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“…As a sole modality, neurointervention in pediatric populations achieves a high cure rate ranging from 84% to 95% in recent literature 11 10. It is also used as a part of multimodal treatment, in combination with radiosurgery or surgery with high cure rates 12–16.…”

Section: Discussionmentioning

confidence: 99%

Pediatric neurointervention: collimation on radiation exposure-associated lifetime excess tumor risk

Paramasivam

Berenstein

2016

J NeuroIntervent Surg

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Curative embolization of pediatric intracranial arteriovenous malformations using Onyx: the role of new embolization techniques on patient outcomes

Abstract: Onyx embolization of AVM in pediatric patients with the intention to cure resulted in high occlusion rates without increasing neurological disability or death. The development of new embolization techniques and devices seems to improve the safety of Onyx embolization.

Cited by 47 publications

References 34 publications

Use of the Apollo detachable-tip microcatheter for endovascular embolization of arteriovenous malformations and arteriovenous fistulas

Use of the Apollo detachable-tip microcatheter for endovascular embolization of arteriovenous malformations and arteriovenous fistulas

Cerebral arteriovenous malformations in the era of embolization for angiographic cure: a single-center experience in Egypt

Pediatric neurointervention: collimation on radiation exposure-associated lifetime excess tumor risk

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