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a guidewire can be passed without any resistance after flushing, the author
sometimes uses the same microcatheter system.
CLINICAL APPLICATIONS
Based on its special features, the use of NBCA as an embolic agent is
theoretically indicated for the following three situations. First, it is optimal to
occlude a vessel with multiple branches or communications to other vessels.
For example, NBCA can be used to embolize atypical vessels responsible for
the arterial supply to liver tumors, such as the inferior phrenic artery. The
inferior phrenic artery is rather long and has many communications with
other arteries (e.g., intercostal arteries, internal mammary artery, etc.). Given
the potential territory supplied by this vessel, NBCA is an effective agent to
use for embolization in this situation (Fig. 9.5). For this reason, NBCA is a
commonly used agent for the treatment of arteriovenous malformations (Fig.
9.6).12 Second, NBCA is used to occlude target vessels when the catheter
position is unstable. Catheter stability is very important when using coils for
embolization because catheters are under tension when coils are being
introduced. If a coil is inserted through a catheter with an unstable position,
the catheter tip may move back and forth, which can lead to coil migration
into an unexpected or undesired location. Instead of coils, NBCA–Lipiodol
mixture can be used in this scenario because it comes out of the catheter in a
few seconds. This may often be the case when embolizing a right gastric
artery for the purpose of redistribution for hepatic infusion chemotherapy and
yttrium 90 infusion (Fig. 9.7),13 portal vein branches for preoperative portal
vein embolization (Fig. 9.8),
14–16
or a bronchial artery in patients with
hemoptysis (Fig. 9.9).17 NBCA has also been shown to be an effective agent
to treat gastrointestinal bleeding.18 Third, NBCA–Lipiodol can potentially be
a more effective embolic agent than coils or particles in coagulopathic
patients.
19,20
Coils and particles rely on normal coagulation for vessel
occlusion. Therefore, if a patient with bleeding is coagulopathic, coils or
particles may not help to stop the bleeding. However, NBCA mixture can
mechanically occupy the intravascular lumen and stop blood flow regardless
of blood coagulability.
An NBCA–Lipiodol mixture can be also used for nonvascular
applications. This mixture is suitable for tract embolization to avoid bleeding
from the tract of blood-rich organ. This may be done in association with
percutaneous biopsy or ablation procedures. The author usually uses NBCA–
Lipiodol mixture after the transsplenic interventions to prevent bleeding from
the spleen (Fig. 9.10).
POTENTIAL COMPLICATIONS
Rosen and Contractor1 defined the complications of NBCA administration as
either being associated with the actual administration of the liquid agent or
being associated with the anatomy of the target vasculature. More
specifically, this can include occlusion of normal territory due to
misinterpretation of anatomy, distal migration or reflux of embolic material,
or artery-to-artery anastomoses; migration of embolic material to the venous
side of the target vascular bed; and catheter gluing.
21
Migration of embolic material to the venous side of a malformation can
potentially lead to venous hypertension or pulmonary emboli. Given the fact
that close fluoroscopic monitoring is typically employed during an NBCA
embolization, the likelihood of a large volume of material passing into the
pulmonary circulation is low. Therefore, this complication is not typically
clinically significant.
22
The gluing of the delivery catheter to the vessel wall is a rare
phenomenon that can be minimized with the use of hydrophilic
microcatheters and NBCA at lower concentrations. It is often due to reflux of
NBCA during embolization, early polymerization, or a failure to retract the
microcatheter in an appropriate amount of time.5 In general, a quick tug on
the microcatheter is often able to separate a microcatheter from a glue cast
due to the relatively low tensile strength of the polymerized NBCA.
1
TIPS AND TRICKS
• There are two colors of NBCA available. One is blue and the other is
clear. When using the clear NBCA, it is important to label the syringe
to prevent it from being confused with contrast or saline.
• To avoid undesirable distribution of an NBCA–Lipiodol mixture,
coils can be deployed in vessels which require protection before
NBCA administration (see Fig. 9.10).
• To embolize a long vessel with NBCA, optimal embolization can be
obtained by pulling back the microcatheter from the distal to the
proximal portion of the vessel during injection (Fig. 9.11). Using this
technique, a vessel with multiple branches or communications to
other vessels can be entirely occluded.
SUMMARY
NBCA is a very useful embolic agent for interventional radiologists in
various clinical applications. Its mechanism of embolization is different from
that of other materials, and there are many technical steps required for the
appropriate handling and administration of NBCA. Acquiring sufficient
knowledge and skills of controlling this unique embolic agent will allow for
its successful use.
REFERENCES
1. Rosen RJ, Contractor S. The use of cyanoacrylate adhesives in the
management of congenital vascular malformations. Semin Intervent
Radiol. 2004;21:59–66.
2. Galil KA, Schonfield ID, Wright GZ. Effect of butyl 2-cyanoacrylate on
the healing of skin wounds. J Can Dent Assoc. 1984;50:565–569.
3. Petrella E, Orlandini G, Poisetti P, et al. A new end to side anastomosis
formed without sutures for hemodialysis fistulas. Nephron.
1975;14:398–400.
4. Kerber CW, Wong W. Liquid acrylic adhesive agents in interventional
neuroradiology. Neurosurg Clin N Am. 2000;11:85–99.
5. Pollak JS, White RI. The use of cyanoacrylate adhesives in peripheral
embolization. J Vasc Interv Radiol. 2001;12:907–913.
6. Schweitzer JS, Chang BS, Madsen P, et al. The pathology of
arteriovenous malformations of the brain treated by embolotherapy.
Neuroradiology. 1993;35:468–474.
7. Brothers MF, Kaufman JC, Fox AJ, et al. N-butyl 2-cyanoacrylate
substitute for IBCA in interventional neuroradiology: histopathological
and polymerization time studies. Am J Neuroradiol. 1989;10:777–786.
8. White RI, Strandberg JV, Gross GS, et al. Therapeutic embolization
with long-term occluding agents and their effects on embolized tissues.
Radiology. 1977;125:677–687.
9. Vinters HV, Galil KA, Lundie MJ, et al. The histotoxicity of
cyanoacrylates: a selective review. Neuroradiology. 1985;27:279–291.
10. Takasawa C, Seiji K, Matsunaga K, et al. Properties of N-butyl
cyanoacrylate-iodized oil mixtures for arterial embolization: in vitro and
in vivo experiments. J Vasc Interv Radiol. 2012;23:1215–1221.
11. Moore C, Murphy K, Gailloud P. Improved distal distribution of n-butyl
cyanoacrylate glue by simultaneous injection of dextrose 5% through the
guiding catheter: technical note. Neuroradiology. 2006;48:327–332.
12. Lee BB, Do YS, Yakes W, et al. Management of arteriovenous
malformations: a multidisciplinary approach. J Vasc Surg. 2004;39:590–
600.
13. Arai Y, Takeuchi Y, Inaba Y, et al. Percutaneous catheter placement for
hepatic arterial infusion chemotherapy. Tech Vasc Interv Radiol.
2007;10:30–37.
14. De Baere T, Denys A, Paradis V. Comparison of four embolic materials
for portal vein embolization: experimental study in pigs. Eur Radiol.
2009;19:1435–1442.
15. Denys A, Lacombe C, Schneider F, et al. Portal vein embolization with
N-butyl cyanoacrylate before partial hepatectomy in patients with
hepatocellular carcinoma and underlying cirrhosis or advanced fibrosis.
J Vasc Interv Radiol. 2005;16(12):1667–1674.
16. Guiu B, Bize P, Gunthern D, et al. Portal vein embolization before right
hepatectomy: improved results using n-butyl-cyanoacrylate compared to
microparticles plus coils. Cardiovasc Intervent Radiol. 2013;36:1306–
1312.
17. Razavi MK, Murphy K. Embolization of bronchial arteries with n-butyl
cyanoacrylate for management of massive hemoptysis: a technical
review. Tech Vasc Interv Radiol. 2007;10:276–282.
18. Yata S, Ihava T, Kaminou T, et al. Transcatheter arterial embolization of
acute arterial bleeding in the upper and lower gastrointestinal tract with
n-butyl 2-cyanoacrylate. J Vasc Interv Radiol. 2013;24:422–431.
19. Yonemitsu T, Kawai N, Sato M, et al. Comparison of hemostatic
durability between n-butyl cyanoacrylate and gelatin sponge particles in
transcatheter arterial embolization for acute arterial hemorrhage in a
coagulopathic condition in a swine model. Cardiovasc Intervent Radiol.
2010;33;1192–1197.
20. Yonemitsu T, Kawai N, Sato M, et al. Evaluation of transcatheter
arterial embolization with gelatin sponge particles, microcoils, and nbutyl cyanoacrylate for acute arterial bleeding in a coagulopathic
condition. J Vasc Interv Radiol. 2009;20:1176–1187.
21. Niimi Y, Berenstein A, Setton A. Complications and their management
during NBCA embolization of craniospinal lesions. Int Neuroradiol.
2003;9(suppl 1):157–164.
22. Pelz DM, Lownie SP, Fox AJ, et al. Symptomatic pulmonary
complications from liquid acrylate embolization of brain arteriovenous
malformations. Am J Neuroradiol. 1997;16:19–26.
O
10
EVOH/DMSO in Peripheral Application
Ricardo Yamada • Andre Uflacker • Austin Bourgeois •
Joshua D. Adams • Marcelo Guimaraes
nyx (Covidien, Irvine, California) was initially manufactured as a
dialysis matrix for separating immunoglobulin from albumin and
then as a matrix for controlled release of chemotherapeutics.
1
However, it was also found to have embolic properties, and its clinical use for
this purpose was first described in 1990 for embolization of intracranial
arteriovenous malformation (AVM).
2
At that time, Onyx showed promising results, overcoming the
drawbacks of cyanoacrylate, a well-known embolic liquid agent commonly
used for the same purpose. The lack of adhesiveness and slow
copolymerization rate permit more distal nidus embolization, sometimes
including the proximal venous outflow, without significant risk of
microcatheter entrapment. After several studies, including a multicenter
randomized trial comparing Onyx and cyanoacrylate, in July 2005, the U.S.
Food and Drug Administration approved its use for intracranial AVM
embolization.3 European device approval (CE marking) preceded that in the
United States by approximately 5 years for embolization of AVMs and
intracranial aneurysms as well. Since then, given the safety and effectiveness
of Onyx in the intracranial vasculature, use on peripheral organs has been
described and successfully applied. Nowadays, it has been used mainly for
the treatment of peripheral AVMs and abdominal aorta stent graft–related
endoleaks.
4–7
In addition, Adamus et al.8 published a series of cases
describing 23 patients in whom Onyx embolization was successfully
performed, including treatment of the renal, hepatic, iliac, and bronchial
arteries and esophageal varices. The authors concluded that Onyx offers
advantages over other embolic agents due to good controllability and faster
vessel occlusion.
8
DEVICE/MATERIAL DESCRIPTION
Onyx is a liquid permanent embolic agent composed of ethylene vinyl
alcohol (EVOH) copolymer dissolved in dimethyl sulfoxide (DMSO) and
micronized tantalum powder. The latter provides contrast for fluoroscopic
visualization. The nonadhesive and viscous properties make it a unique agent,
mostly differing from the other two known liquid embolic agents—glue and
dehydrated alcohol. Its nonadhesive characteristic significantly decreases the
risk of microcatheter entrapment, compared to glue (Table 10.1). The higher
viscosity allows controlled deployment, which is extremely difficult to
achieve with dehydrated alcohol.
The Onyx package includes three 1-mL delivery syringes, two labeled
for Onyx use (white plunger) and one for DMSO (yellow plunger); one 1.5mL vial of Onyx; and one 1.5-mL vial of DMSO (Fig. 10.1). The Onyx white