Initial experience with dual-lumen balloon catheter injection for preoperative Onyx embolization of skull base paragangliomas

Abstract

P aragangliomas are highly vascular head and neck tumors. As early as 1975, preoperative embolization before resection has been advocated as a means to improve postoperative outcomes through the minimization of blood loss and better visualization of surgical planes. 4,7 Given its flow characteristics, Onyx (Covidien) has seen increasing use in the preoperative embolization of tumors, including paragangliomas. 1,3,5,6,17,20,25 Direct percutaneous puncture is currently the most reported route for Onyx embolization of these tumors, although it is unclear whether that reflects a publication bias or if this modality is actually more common than using transarterial routes of embolization. 3,17,20,25 Problems with conventional transfemoral artery access, such as tortuosity, atherosclerosis, vasospasm, and small-caliber arterial feeders, may impede complete embolization of these tumors, and dangerabbreviatioNs EBL = estimated blood loss; ECA = external carotid artery; ICA = internal carotid artery; PVA = polyvinyl alcohol. obJective Paragangliomas are highly vascular head and neck tumors for which preoperative embolization is often considered to facilitate resection. The authors evaluated their initial experience using a dual-lumen balloon to facilitate preoperative embolization in 5 consecutive patients who underwent preoperative transarterial Onyx embolization assisted by the Scepter dual-lumen balloon catheter between 2012 and 2014. methods The authors reviewed the demographic and clinical records of 5 patients who underwent Scepter-assisted Onyx embolization of a paraganglioma followed by resection between 2012 and 2014. Descriptive statistics of clinical outcomes were assessed. results Five patients (4 with a jugular and 1 with a vagal paraganglioma) were identified. Three paragangliomas were embolized in a single session, and each of the other 2 were completed in 3 staged sessions. The mean volume of Onyx used was 14.3 ml (range 6-30 ml). Twenty-seven vessels were selectively catheterized for embolization. All patients required selective embolization via multiple vessels. Two patients required sacrifice of parent vessels (1 petrocavernous internal carotid artery and 1 vertebral artery) after successful balloon test occlusion. One patient underwent embolization with Onyx-18 alone, 2 with Onyx-34 alone, and 1 with Onyx-18 and -34. In each case, migration of Onyx was achieved within the tumor parenchyma. The mean time between embolization and resection was 3.8 days (range 1-8 days). Gross-total resection was achieved in 3 (60%) patients, and the other 2 patients had minimal residual tumor. The mean estimated blood loss during the resections was 556 ml (range 200-850 ml). The mean postoperative hematocrit level change was -17.3%. Two patients required blood transfusions. One patient, who underwent extensive tumor penetration with Onyx, developed a temporary partial cranial nerve VII palsy that resolved to House-Brackmann Grade I (out of VI) at the 6-month follow-up. One patient experienced improvement in existing faci...

Middle meningeal artery: Gateway for effective transarterial Onyx embolization of dural arteriovenous fistulas

“…The long course within the dural leaflets also allows for Onyx reflux over a longer distance creating additional support during the catheter pull. Due to its relatively small lumen the MMA is less suitable for Onyx embolization through a dual-lumen balloon catheter, an approach advocated for preoperative embolization of spinal or skull base tumors (Ladner et al, 2014;Ladner et al, 2015). The occipital artery, the second most likely artery to supply a dAVF in this series, follows a more tortuous, transosseous course which inhibits microcatheter access, navigation, and Onyx penetration.…”

“…The long course within the dural leaflets also allows for Onyx reflux over a longer distance creating additional support during the catheter pull. Due to its relatively small lumen the MMA is less suitable for Onyx embolization through a dual‐lumen balloon catheter, an approach advocated for preoperative embolization of spinal or skull base tumors (Ladner et al, ; Ladner et al, ).…”

Facial Nerve Paralysis after Onyx Embolization of a Jugular Paraganglioma: A Case Report with a Long-Term Follow Up

“…In all reported cases, patients with complete FN paralysis (H-B grade VI) never had recovery, while all patients with partial paralysis after embolization showed improvement of their FN function and some had complete function recovery [ 9 , 10 ]. Our patient got partial FN function improvement from H-B grade V to II at the last follow-up visit.…”

“…When embolization of vessels involved in the blood supply of a cranial nerve is required, using a dual-lumen balloon catheter to prevent the flow of Onyx fragments proximally with slow injection rate or using other temporary occluding agents like polyvinyl alcohol with high recanalization rate were found to be useful in decreasing the risk of nontarget vessel occlusion and neural ischemia with permanent cranial nerves deficits [ 9 , 10 ]. Furthermore, direct percutaneous injection of Onyx inside the tumor is another alternative route to the transarterial one, with no reported cases of post-embolization neuropathy; however, the safety of this technique is not well-established, as few cases of JPs have been embolized using this procedure [ 5 , 10 ].…”

Septoplasty: Scepter Balloon Angioplasty for Vasospasm after Aneurysmal Subarachnoid Hemorrhage

“…Its utility as a balloon adjunct for aneurysm coiling [11], arteriovenous malformation embolization [12,13,14], and tumor embolization [15,16] has been described. Its dual coaxial lumen design accommodates a 0.014-inch microwire, allowing for more facile microcatheter delivery, enhanced stability/reduced “watermelon seeding,” and the ability to infuse a vasodilator superselectively prior to angioplasty.…”