Preoperative Embolization of Fisch Grades II–IVa Juvenile Nasopharyngeal Angiofibromas: Transarterial Embolization in the Age of Onyx

Abstract

The current mainstay treatment for juvenile nasopharyngeal angiofibromas (JNAs) is surgical resection, but embolization of primary feeding arteries through endovascular transarterial and direct tumoral puncture embolizations with various agents has been described. We describe a single institutional experience with JNA embolization utilizing Onyx (Medtronic, Dublin, Ireland). MethodsA retrospective records review was performed to identify patients who underwent embolization for devascularization of Fisch grades II-IVa JNA (tumor extension beyond the sphenopalatine region) before surgical resection between 2010 and 2019. Fluoroscopy time, grade, intraoperative blood loss, and clinical follow-up data were compiled. Tumor devascularization percentage was calculated using ImageJ software (public domain, BSD-2) by measuring the ratio of preoperative and postoperative embolization tracing. ResultsFive consecutive patients (ages 12-16 years [average 14 years]; all male) with JNAs underwent preoperative transarterial embolizations performed under general anesthesia. All patients presented with epistaxis; two also presented with headaches. Fisch grades were II in two patients, IIIa in two, and IVa in one. The patient with the grade IVa lesion underwent direct transtumoral puncture and Onyx embolization. The mean percentage of all tumor devascularizations postembolization was 86.0±9.7%. Complete resection 24-48 hours postembolization was obtained for grades II and IIIa lesions with <700 mL blood loss. No embolization-related complications and no clinical sequelae were present in the five cases after embolization. ConclusionIn our experience, Onyx embolization of JNAs was safely conducted with adequate tumor penetration beyond the sphenopalatine region through transarterial routes.

Case of IV Stage Juvenile Nasopharyngeal Angiofibroma Presurgically Treated with a Single ECA Stop-Flow Embolization Technique Using Onyx 18

“…Although Onyx formulation 34 (more viscous) is more frequently used, in the literature also, formulation 18 (more fluid) has been employed [ 9 , 10 ] for hypervascular lesion treatment and both can be used in the same procedure [ 6 ].…”

Preoperative Embolization Techniques in the Treatment of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review

“…Cyanoacrylate and Onyx are both liquid polymers that result in permanent casting and thrombosis of vessels once the materials contact blood 32 . Both materials have been shown to be safe and effective in reducing intraoperative blood loss and improving visualization during JNA resection, although no study included in this analysis utilized Onyx 9,33‐35 . Reports of embolic stroke have been reported with these materials, highlighting the need for caution 36,37 .…”

“…32 Both materials have been shown to be safe and effective in reducing intraoperative blood loss and improving visualization during JNA resection, although no study included in this analysis utilized Onyx. 9,[33][34][35] Reports of embolic stroke have been reported with these materials, highlighting the need for caution. 36,37 While cyanoacrylate rapidly polymerizes, and is often diluted to prolong the polymerization time, Onyx polymerizes more slowly, affording a prolonged injection period.…”

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

“…Typically, angiography with embolization is performed 24–72 h prior to surgery. A variety of embolic agents are employed, frequently including polyvinyl alcohol, gelatin sponge, microcoils, and radiopaque liquid embolic agents (e.g., Onyx, ethylene vinyl alcohol copolymer) 5,777,795–799 . Numerous studies have shown that preoperative embolization is associated with reduction in intraoperative blood loss, though some studies suggest this benefit is limited to the advanced‐stage cases 5,777,796,797,800 .…”