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H
16
Vascular Tumors
Robert F. James • Lacey B. Martin • John R. Gaughen, Jr •
William J. Mack
ighly vascular tumors of the head and neck often pose significant
surgical challenges. Bleeding can result in decreased operative
visibility and inadvertent injury to adjacent vital structures.
Significant blood loss and volume depletion can lead to major morbidities.
Embolization of vascular head and neck tumors before surgical resection may
help to minimize blood loss, reduce operative time, and facilitate surgical
resection. However, the additional endovascular procedure is not without risk
to the patient. Multiple anastomotic connections exist between the arteries of
the head and neck. Aberrant embolization through these channels can lead to
neurologic injuries such as visual loss, paralysis, or ischemic injury to the
cranial nerves. It is imperative that the interventionalist and the operating
surgeon discuss the goals of embolization and the overall treatment plan
before the endovascular procedure. The most common vascular tumors of the
head and neck region suitable for preoperative embolization include
meningiomas, paragangliomas, juvenile nasopharyngeal angiofibromas,
hemangiopericytomas, and hemangioblastomas. Here we will discuss the
relevant procedure-related devices and materials, techniques, clinical
applications, and potential complications. Most discussion focuses on
meningiomas as they are the most frequently encountered of the vascular
head and neck tumors. Subsections are devoted to specific concerns for the
other tumor types. Table 16.1
details important dangerous anastomoses with
the cranial nerve blood supply.
DEVICE/MATERIAL DESCRIPTION
Catheters
A coaxial system of an outer guide catheter and an inner microcatheter is
usually employed for transarterial endovascular embolization. We typically
use guide catheters with a 0.053-in or 0.070-in inner diameter. The 6-Fr 070
Neuron guide catheter (0.070-in inner diameter; Penumbra, Inc., Alameda,
California) can be used for the internal carotid artery (ICA) access, the 053
Neuron guide catheter for the external carotid artery (ECA) (0.053-in inner
diameter), and either the 053 or 070 Neuron guide catheter for the vertebral
artery (VA), depending on vessel diameter.
There are various-sized microcatheters with multiple features that are
beyond the scope of this chapter. The Echelon-10 and Marathon (Covidien,
Irvine, California) microcatheters can be used for routine embolizations. The
Scepter C balloon catheter (MicroVention, Inc., Tustin, California) enables a
new balloon-augmented embolization technique through a single
microcatheter.
1
,2
Typically, 0.014-in diameter guidewires are used to help
navigate the microcatheter because of their superior steering and trackability.
However, smaller guidewires such as the 0.008-in Mirage (Covidien, Irvine,
California) may be safer in small, distal cerebral vasculature (Note: the
0.008-in guidewires are essentially unsteerable and navigating bifurcations is
often an exercise in persistence of the trial and error technique and/or
uncanny tip reshaping proficiency). The size and angioarchitecture of the
feeding vessel may require altering or modifying the microcatheter, often
necessitating very small and “floppy” catheters for difficult-to-reach
anatomy. In these situations, the Marathon flow-directed microcatheter could
be advantageous. Unfortunately, guidewires 0.012 in or smaller are necessary
when using the Marathon microcatheter due to its 0.013-in distal lumen
diameter. However, the catheter is surprisingly compatible with the 0.014-in
Traxcess guidewire (MicroVention, Inc., Tustin, California), as both the
catheter and wire taper in a similar fashion. Preference is given to use the
0.014-in Traxcess guidewire when the Marathon microcatheter is required, as
the Traxcess wire has superior steerability and provides a more rigid tracking
platform compared to the other compatible guidewires.
Particles
The most common agent used for embolization of meningiomas and other
head and neck tumors is a suspension of particles mixed with a contrast
agent. Particles are small substrates that aggregate to obstruct the vessel. The
choices of particle material and size impact results and potential
complications associated with embolization. As differences in the
granulometric distribution of particles exist, they may not match exactly with
their advertised size range. Compressibility, elastic recovery, aggregation,
and visualization of particles can all affect performance.
Polyvinyl alcohol (PVA) particles are nonspherical and are available in
preparations of varying size ranges. Limitations with PVA embolization
include difficulty with aggregation and microcatheter obstruction, leading to
premature termination of the embolization or microcatheter exchange.
Injection under increased pressure to clear the catheter should never be
performed. This maneuver increases the risk of forcing particles into
undesired territories once they are released.
Smaller particles allow deeper penetration into the tumor bed for more
complete devascularization and increased tumor necrosis; however, they have
a higher likelihood of reaching potentially dangerous or disabling arteries.
3
Larger particles are safer but may not fully penetrate and devascularize the
tumor bed and, therefore, may be less efficient at reducing surgical blood
loss. Maintaining particle size greater than 150 µm is thought to reduce the
risk of damaging the vasa nervorum of the cranial nerves.
4,5
A large study of
201 embolized meningiomas found small particle size (45 to 150 µm) to be
the sole risk factor for complications, hemorrhagic or otherwise.5 In highflow situations, increasing particle size to greater than 500 µm may be
beneficial, or an alternate class of embolic agent can be considered. Size
selection of the PVA particles is a balance between desired tumor penetration
and unwanted target embolization. In most situations, selecting particles with
a diameter between 150 and 350 µm will provide optimal results.
6
Trisacryl Microspheres
Calibrated spherical particles made of trisacryl and cellulose porous beads
were developed to address the disadvantages of PVA particles, specifically
their irregular size and nonspherical nature. Trisacryl microspheres are
partially compressible and, as a result, allow for easier transit through the
delivery catheter.
7,8
Microspheres are thought to redistribute after initial
clumping and delayed control angiography is therefore warranted. A study of
60 patients comparing trisacryl particles to nonspherical PVA particles found
lower surgical blood loss with trisacryl embolization.
9
Gelfoam
Gelfoam should be delivered via the transarterial embolization approach. For
head and neck tumors, powder and sponge forms can be used.10 Gelfoam
persists for 3 to 6 weeks before recanalization begins.
Liquid Embolics
The two most common liquid embolic agents are N-butyl cyanoacrylate
(NBCA: Trufill; Codman & Shurtleff, Inc., Raynham, Massachusetts) and
ethylene vinyl alcohol (Onyx; Covidien, Irvine, California). The choice of
liquid embolic is a matter of preference, with each having advantages and
disadvantages. Onyx offers a decreased theoretical risk of catheter retention,
whereas NBCA has more versatility by altering the rate of polymerization
with dilution strategies.
Advantages of liquid embolic agents include decreased peritumoral
edema and the prevention of delayed recanalization (sometimes seen after
particle embolization). They can be used with transarterial or direct puncture
embolization techniques. Potential disadvantages include an inability to select
the size of vessels that the liquid embolic will enter (compared to particle
embolization). There is risk that the liquid embolic agent will occlude vessels
prematurely without deep penetration into the tumor.11 Further, liquid
embolics are more expensive than particles.
NBCA is a liquid embolic that is injected as a mixture with Ethiodol.
The safety of tumor embolization with NBCA has been studied. Kim et al.
12
examined 35 consecutive tumor patients embolized with NBCA (17%
meningiomas). The authors suggest that NBCA had better fluoroscopic
visibility than PVA particles, enabling precise identification of embolized
vessels and tumor mass. Disadvantages include quicker polymerization and
risk of catheter retention. Proper embolization with NBCA requires greater
technical skill than PVA administration. NBCA is also considered more
permanent than PVA particles. When dangerous anastomoses are
encountered, coils can be used to obstruct their origins and prevent distal
embolization of the liquid embolic agent into unwanted territories.
12
Onyx is an effective embolic agent that can penetrate into tumor
capillaries. A small case series reported no increased postembolization tumor
edema and no hemorrhagic complications following Onyx embolization.
11
The Onyx mixture is radiopaque and highly visible during angiography.
13
Care must be taken to create a meniscus between the dimethyl sulfoxide
(DMSO) and the Onyx. Mixing of Onyx and DMSO in the catheter hub can
dilute the Onyx, rendering it less radiopaque and more difficult to visualize.
This can increase the risk of embolization to unwanted vascular territories.
Onyx can be injected over a longer time frame than NBCA, which makes it
more controllable and therefore may result in more uniform lesion
penetration.
14
Coils
Coils are shaped (curled) pieces of metal, usually platinum, that are released
into a vessel for occlusion. Detachable and pushable coils can serve as an
alternative to particle and liquid embolization methods. Some debate exists
regarding the appropriateness and use of coils in the setting of head and neck
tumors. Coils may be suitable for masses with large feeding vessels, greater
than 1.5 mm in diameter.15 However, some argue that proximal coil
occlusion may not only create collaterals but may also prevent repeat access
in case of tumor recurrences.16 Coils can be an excellent adjunct to liquid
embolization, preventing penetration of the liquid embolic into unwanted
territories without causing ischemia.
Other Embolic Agents
Additional agents that have been used in embolization of vascular head and
neck tumors include fibrin glue, ethyl alcohol (ETOH), hydroxyapatite
ceramics, phenytoin, hyperosmolar mannitol, and Lipiodol.
17–22
TECHNIQUE
Preembolization Workup and Considerations
A complete medical history and physical examination is required before any
embolization procedure. A review of noninvasive imaging is critical; findings
on computed tomography (CT) and magnetic resonance imaging (MRI)
studies can help guide the treatment. A complete angiographic evaluation of
the tumor is recommended. For intracranial meningiomas, a comprehensive
study includes a six-vessel intracranial and extracranial angiogram (bilateral
ECA, ICA, and VA). Large vessel sacrifice may be warranted when
paragangliomas encase the carotid artery. In these cases, angiography can be
combined with balloon test occlusion to assess the feasibility of vessel
sacrifice.
23
Subsequently, superselective angiography of individual arterial pedicles,
with specific attention to dangerous anastomoses and the at-risk blood supply
of cranial nerves, is necessary to plan the embolization procedure (Table
16.1).24 Blood supply to most meningiomas is derived from the dural arterial
vasculature (middle meningeal artery, posterior meningeal artery, tentorial
artery of Bernasconi and Cassinari, etc.), arising from the ECA, VA, or ICA.
A typical finding on superselective angiography is an intense vascular tumor
blush from the arterial phase through the late venous phase, often with a
“sunburst” type pattern.25 Tumors located in specific anatomical locations
such as the orbital, parasellar, petroclival, and cervicomedullary regions will
have associated, and predictable, patterns of these dangerous anastomoses or
at-risk cranial nerve blood supply relative to their location.24 Careful study of
the superselective angiographic images with a strong understanding of the
usual dangerous anatomy is imperative for the avoidance of complications.