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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
• The residual DMSO volume, after the dead space injection, should be
used to overwash the hub to avoid any air bubble at the back of the
syringe.
• If the microcatheter tip is far away from the nidus (in AVMs) or from
target lesion, consider Onyx 18. If it is close to the target or if it is
desired to have better control during the injection, consider Onyx 34.
Onyx 500 is typically used for giant aneurysms.
• Once Onyx is injected through the microcatheter tip, attention should
be paid on the reflux toward the hub of the microcatheter. It is desired
to form a short plug around the tip that will allow further injection of
Onyx to be pushed forward.
• Differently than glue, Onyx may be slowly injected for several
minutes as long as adequate plug is formed and there is no
interruption in the column of Onyx injection.
• Onyx occupies free space by sedimentation; it does not polymerize
like glue. However, microcatheter tip still can get trapped if the plug
created around the tip gets too long (>2 cm).
• In case the microcatheter tip gets trapped, it typically will come out if
a gentle, continuous pullback is applied from the hub of the
microcatheter. Avoid sudden and intense pullback.
REFERENCES
1. Kayashima K, Sueoka A, Smith JW, et al. Development of new hollow
fiber membrane macromolecular filters. Trans Am Soc Artif Intern
Organs. 1982;28:66–70.
2. Taki W, Yonekawa Y, Iwata H, et al. A new liquid material for
embolization of arteriovenous malformations. AJNR Am J Neuroradiol.
1990;1(1):163–168.
3. U.S. Multicenter, Randomized Controlled Study Comparing the
Performance of Onyx (EVOH) and TRUFILL (n-BCA) in the
Presurgical Embolization of Brain Arteriovenous Malformations
(BAVMs). Washington, DC: Georgetown University Hospital; 2003.
4. Castaneda F, Goodwin SC, Swischuk JL, et al. Treatment of pelvic
arteriovenous malformations with ethylene vinyl alcohol copolymer
(Onyx). J Vasc Interv Radiol. 2002;13(5):513–516.
5. Numan F, Omeroglu A, Kara B, et al. Embolization of peripheral
vascular malformations with ethylene vinyl alcohol copolymer (Onyx). J
Vasc Interv Radiol. 2004;15(9):939–946.
6. Martin ML, Dolmatch BL, Fry PD, et al. Treatment of type II endoleaks
with Onyx. J Vasc Interv Radiol. 2001;12(5): 629–632.
7. Nevala T, Biancari F, Manninen H, et al. Type II endoleak after
endovascular repair of abdominal aortic aneurysm: effectiveness of
embolization. Cardiovasc Intervent Radiol. 2010;33(2):278–284.
8. Adamus Nurnberg R, Uder Erlangen M, Kleinschmidt T, et al.
Embolization of acute abdominal and thoracic hemorrhages with
ethylene vinyl alcohol copolymer (Onyx): initial experiences with
arteries of the body trunk [in German]. Rofo. 2010;182(10):900–904.
9. Jahan R, Murayama Y, Gobin YP, et al. Embolization of arteriovenous
malformations with Onyx: clinicopathological experience in 23 patients.
Neurosurgery. 2001;48(5):984–995.
10. Bratby MJ, Lehmann ED, Bottomley J, et al. Endovascular embolization
of visceral artery aneurysms with ethylene-vinyl alcohol (Onyx): a case
series. Cardiovasc Intervent Radiol. 2006;29(6):1125–1128.
11. Vanninen RL, Manninen I. Onyx, a new liquid embolic material for
peripheral interventions: preliminary experience in aneurysm,
pseudoaneurysm, and pulmonary arteriovenous malformation
embolization. Cardiovasc Intervent Radiol. 2007;30(2):196–200.
12. Lenhart M, Paetzel C, Sackmann M, et al. Superselective arterial
embolisation with a liquid polyvinyl alcohol copolymer in patients with
acute gastrointestinal haemorrhage. Eur Radiol. 2010;20(8):1994–1999.
13. Guimaraes M, Wooster M. Onyx (ethylene-vinyl alcohol copolymer) in
peripheral applications. Semin Intervent Radiol. 2011;28(3):350–356.
14. Massis K, Carson WG III, Rozas A, et al. Treatment of type II endoleaks
with ethylene-vinyl-alcohol copolymer (Onyx). Vasc Endovascular
Surg. 2012;46(3):251–257.
15. Moret J, Cognard C, Weill A, et al. Reconstruction technic in the
treatment of wide-neck intracranial aneurysms. Long-term angiographic
and clinical results. Apropos of 56 cases [in French]. J Neuroradiol.
1997;24(1):30–44.
S
11
Sclerosing Agents
Jordan C. Tasse • Bulent Arslan • Ulku Cenk Turba
clerosing agents represent another category of liquid embolic agents.
They act by damaging endothelial cells, leading to an inflammatory
fibrosis and irreversible vascular thrombosis. The sclerosant effect
typically depends on the strength of the particular agent being used and the
amount of time that it is in contact with the endothelial lining of the vessel.
ABSOLUTE ALCOHOL (ETHANOL)
Alcohol is one of the most potent of the liquid embolic agents. It can be
injected using a catheter-based intravascular approach or using a direct
percutaneous approach. Absolute alcohol is an effective permanent
embolization agent that has been used in various scenarios. Some of the
applications of absolute alcohol include percutaneous tumor
ablation/treatment, presurgical embolization of renal cell carcinoma, and
treatment of vascular malformations. Direct alcohol injection has been used
for treatment of small (<2 cm) hepatocellular carcinomas and for
sclerotherapy of painful abdominal cysts and postsurgical seromas.
Alcohol acts by denaturing endothelial proteins, leading to activation of
the coagulation cascade inducing subsequent thrombosis.1 Ethanol also
induces vasospasm. Occlusion is typically seen within seconds after injection
and progresses for several days. The effect depends on ethanol concentration,
time of exposure, and injection rate; rapid injection rates produce more
endothelial damage and parenchymal necrosis with less thrombosis, whereas
slower injection rates produce more thrombosis but less endothelial damage
and necrosis.
2
The use of alcohol as an embolic agent is not without risk. The
disadvantages of alcohol include the risk of damage to surrounding tissues
including nerves, skin, and mucosa due to its penetrative properties. Patients
may experience severe procedural pain. Monitoring for systemic toxicity is
also crucial when the dose of alcohol is greater than 1 mL/kg or if the total
volume exceeds 60 mL. The side effects may include central nervous system
depression, hemolysis, and cardiac arrest.
Given these possible effects, it is important to minimize the incidence of
nontarget embolization. The techniques used to reduce this risk include slow
injection, use of balloon occlusion of the arterial inflow, or balloon occlusion
of the draining vein.
ETHANOLAMINE OLEATE
Ethamolin (QOL Medical, LLC, Kirkland, Washington)
Ethanolamine oleate is a salt of a fatty acid with excellent thrombogenic
properties. It is typically injected as a mixture consisting of 5% ethanolamine
oleate and nonionic contrast material or iodized oil (5:1 ratio) for radiopacity.
It combines its inherent thrombogenic properties with an inflammatory
response to oleic acid that occurs in the vascular wall. When compared to
ethanol, ethanolamine oleate has a less penetrating effect in comparison and
is therefore considered safer to use in vascular structures with close proximity
to nerves, skin, and mucosa.
Ethanolamine oleate has most commonly been used for sclerosis of
gastroesophageal varices, venous malformations, and sclerotherapy of cyst,
seromas, etc. Some risks associated with ethanolamine oleate include renal
failure, pulmonary edema, and anaphylaxis. Although it is considered
experimental, haptoglobin can be administered with ethanolamine oleate to
bind free hemoglobin and albumin before injection to prevent hemolysis-
induced renal insufficiency.
3
SODIUM TETRADECYL SULFATE
Sotradecol (AngioDynamics, Queesnbury, New York), FibroVein (STD
Pharmaceuticals Ltd., Hereford, United Kingdom), Trombovar (Aventis
Pharma, Le Trait, France), Tromboject (Omega Laboratories Ltd.,
Montreal, Quebec, Canada)
Sodium tetradecyl sulfate (STS; Sotradecol) is a long-chain fatty acid salt
with detergent properties. It is an effective sclerosing agent that acts by
inducing endothelial damage and dissolution of the endothelial cell
membrane, which causes cell overhydration. Sotradecol is U.S. Food and
Drug Administration (FDA) approved for distribution in 1% and 3%
concentrations. It is typically mixed with a water-soluble contrast agent to
provide radiopacity. It can also be mixed with iodized poppy seed oil (i.e.,
Lipiodol) with air or carbon dioxide to create a foam.4 Foamed detergent
sclerosants have been reported to be more potent than their liquid
counterpart.
5
Sotradecol has been in use for more than 50 years and can be injected
via an intravascular route or a direct percutaneous approach. Typical uses
include the direct injection of varicose veins (0.1% to 3% concentration),
sclerosis of gonadal veins in the management of varicoceles and pelvic
congestion syndrome (1% to 3% concentration), sclerotherapy of peripheral
venous malformation (1% to 3% concentration), as well as balloon-occluded
retrograde transvenous obliteration (BRTO) procedures for bleeding gastric
varices treatment (Fig. 11.1).
POLIDOCANOL
Asclera (Merz Aesthetics, San Mateo, California), Aethoxysclerol
(Kreussler Pharma, Wiesbaden, Germany)
Polidocanol is the most widely used venous sclerosant in Europe and was
recently approved by the FDA for use in the United States. It consists of 95%
hydroxypolyethoxydodecane, a cationic detergent with anesthetic properties.
Similar to STS, its detergent action induces rapid overhydration of
endothelial cells, leading to vascular injury. Polidocanol can be obtained in
1% and 3% concentrations, and its potency is approximately half of
Sotradecol. Polidocanol has been used to treat lower extremity varicosities
and venous malformations. Its anesthetic properties have been reported to
significantly reduce procedure-related pain.
6
The risks of polidocanol administration include anaphylaxis and cardiac
depression. The cardiac effects are due to its anesthetic properties, which
cause depression in the electrical excitability of and conduction rate through
the heart and spontaneous pacemaker activity in the sinus node, resulting in
sinus bradycardia and possible sinus arrest.
7
Table 11.1 summarizes the aforementioned agents.
SODIUM MORRHUATE
Scleromate (Glenwood LLC, Englewood, New Jersey)
Sodium morrhuate is a sclerosing agent composed of a sodium salt of fatty
acids in cod liver oil. The agent has been used in the treatment of varicose
veins and venous malformations. It has been reported to be 1.5 to 4 times less
effective than Sotradecol.8 Additionally, high rates of anaphylaxis and
complications from extravasation, including pain and tissue necrosis, have
limited its use.
ETHIBLOC
Ethibloc (Ethicon, Norderstedt, Germany)
Ethibloc consists of a solution of zein, sodium amidotrizoate, oleum
papaveris, and propylene glycol. It has been used effectively for the treatment
of venous, lymphatic, and arteriovenous malformations. It requires
approximately 15 minutes to solidify into a viscous solution, allowing it to
remain static within the target lesion to cause intravascular thrombosis,
necrosis, and fibrosis.
OTHERS
In general, there are various sclerosing agents. In addition to the
aforementioned agents, any agent that has detergent properties, hyperosmolar
agents, chemical irritants, and even antibiotics (doxycycline, erythromycin,
etc.) may be used as sclerosing agents. The impact of the treatment is
generally determined by the tissue/endothelium contact time and strength of
the sclerosing agent.
TIPS AND TRICKS
Tips
• Ethanol injection is painful and anesthesia assistance should be
considered.
• Always use a microcatheter coaxial to the diagnostic catheter or a
triaxial system with elongated sheath to provide optimal stability.
• Be careful during diagnostic angiography for an arteriovenous
malformation to identify high-flow versus low-flow lesion for
potential alcohol injection.
• Perform thorough diagnostic angiography during BRTO to identify
any complex outflow and ensure that occlusion balloon is above all
outflow veins to maximize treatment and prevent nontarget
embolization.
Tricks
• Contrast injection is helpful to estimate volume of sclerosant
necessary in BRTO procedures.
• Ethanol should be mixed with nonionic contrast in a 1:1 ratio to allow
optimal visualization.
• For limb lesions, use a tourniquet to decrease venous outflow and
systemic effects of sclerosants.
• For small lesions, use small 1.7-Fr to 2.1-Fr microcatheters.
• Use vascular plugs to complement sclerosant for gonadal vein
embolization to decrease coil use and procedure time and to maximize
embolization effect.
CONCLUSION
Sclerosing agents can be used as an embolic agent for several different
indications. Given their liquid form and mechanism of action, the potential
does exist for unintended distal embolization and tissue effects not seen with
other agents. Therefore, care must be taken when using these agents.
REFERENCES
1. Do YS, Yakes WF, Shin SW, et al. Ethanol embolization of
arteriovenous malformations: interim results. Radiology.
2005;235(2):674–682.
2. Ellman BA, Parkhill BJ, Marcus PB, et al. Renal ablation with absolute
ethanol: mechanism of action. Invest Radiol. 1984;19(5):416–423.
3. Kato GJ. Haptoglobin halts hemoglobin’s havoc. J Clin Invest.
2009;119(8):2140–2142. doi:10.1172/JCI40258.
4. Sabri SS, Swee W, Turba UC, et al. Bleeding gastric varices obliteration
with balloon-occluded retrograde transvenous obliteration using sodium
tetradecyl sulfate foam. J Vasc Interv Radiol. 2011;22(3):309–316.
5. Cabrera J, Cabrera J Jr, Garcia-Olmedo MA, et al. Treatment of venous
malformations with sclerosant in microfoam form. Arch Dermatol.