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J Neurol Surg A Cent Eur Neurosurg 2015; 76(04): 309-317
DOI: 10.1055/s-0034-1394191
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Comparing Angiographic Devascularization with Histologic Penetration after Preoperative Tumor Embolization with Onyx: What Indicates an Effective Procedure?

Ramesh Grandhi
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Christopher T. Hunnicutt
2   Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Gillian Harrison
3   Department of Neurosurgery, New York University Langone Medical Center, New York, United States
,
Nathan T. Zwagerman
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Carl H. Snyderman
4   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Paul A. Gardner
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Douglas J. Hartman
5   Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Michael Horowitz
6   Department of Neurosurgery, Pennsylvania Brain and Spine Institute, Mars, Pennsylvania, United States
› Author Affiliations
Further Information

Publication History

11 October 2013

26 June 2014

Publication Date:
16 January 2015 (online)

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Abstract

Background and Purpose To assess Onyx (Covidien, Irvine, California, United States) efficacy as a preoperative embolic agent for neoplasms of the head, neck, and spine, and to compare angiographic and histologic evidence of tumor penetration as predictors of intraoperative blood loss.

Materials and Methods Retrospective analysis of preoperative Onyx embolization procedures for treatment of head, neck, and spine tumors from 2009 to 2011. Patient demographics and information relating to the embolization procedure and operation were recorded. Measures of Onyx efficacy included intraoperative blood loss and length of surgery. Angiographic and histologic penetration, in addition to percentage of tumor devascularization, were assessed as predictors of efficacy.

Results A total of 22 patients with 17 head or neck and 5 spinal lesions underwent trans-arterial preoperative Onyx embolization. Good angiographic penetration was reported in 41% of tumors and central histologic penetration in 59%, with mean tumor devascularization of 85.3% (standard deviation [SD]: 12.6%). There was no relationship between angiographic and histologic Onyx penetrance. Mean surgical blood loss was 1342 mL (SD: 1327 mL), and length of surgery was 289 minutes (SD: 162 minutes). Neither angiographic, nor histologic Onyx penetration predicted intraoperative blood loss (p = 0.38 and p = 0.32, respectively) or surgical length (p = 0.62 and 0.90, respectively). Devascularization was not associated with blood loss (p = 0.62), but it was a negative predictor of surgical length (p = 0.013).

Conclusions Preoperative Onyx embolization of head, neck, and spine tumors is capable of deep histologic tumor penetration, even when not visualized on angiography. The lack of association between measures of procedural adequacy suggests that using angiographic devascularization as a measure of procedural efficacy may be of limited utility.

Keywords

Onyx - embolization - endovascular
 

  • References

  • 1 Ayad M, Eskioglu E, Mericle RA. Onyx: a unique neuroembolic agent. Expert Rev Med Devices 2006; 3 (6) 705-715
    CrossrefPubMedGoogle Scholar
  • 2 Gore P, Theodore N, Brasiliense L , et al. The utility of onyx for preoperative embolization of cranial and spinal tumors. Neurosurgery 2008; 62 (6) 1204-1211 ; discussion 1211–1212
    CrossrefPubMedGoogle Scholar
  • 3 Gobin YP, Murayama Y, Milanese K , et al. Head and neck hypervascular lesions: embolization with ethylene vinyl alcohol copolymer—laboratory evaluation in swine and clinical evaluation in humans. Radiology 2001; 221 (2) 309-317
    CrossrefPubMedGoogle Scholar
  • 4 Quadros RS, Gallas S, Delcourt C, Dehoux E, Scherperel B, Pierot L. Preoperative embolization of a cervicodorsal paraganglioma by direct percutaneous injection of Onyx and endovascular delivery of particles. AJNR Am J Neuroradiol 2006; 27 (9) 1907-1909
    PubMedGoogle Scholar
  • 5 Rimbot A, Mounayer C, Loureiro C , et al. Preoperative mixed embolization of a paraganglioma using Onyx [in French]. J Neuroradiol 2007; 34 (5) 334-339
    CrossrefPubMedGoogle Scholar
  • 6 Hu YC, Newman CB, Porter RW, Albuquerque FC. Transarterial Onyx embolization of sacral chordoma: case report and review of the literature. J Neurointerv Surg 2011; 3 (1) 85-87
    CrossrefPubMedGoogle Scholar
  • 7 Tampieri D, Leblanc R, TerBrugge K. Preoperative embolization of brain and spinal hemangioblastomas. Neurosurgery 1993; 33 (3) 502-505 ; discussion 505
    CrossrefPubMedGoogle Scholar
  • 8 Seong Eom K, Won Kim D, Sung Choi S, Ha Choi K, Young Kim T. Preoperative embolization of a cerebellar haemangioblastoma using Onyx: case report and literature review. Neurol Neurochir Pol 2011; 45 (3) 292-296
    PubMedGoogle Scholar
  • 9 Olerud C, Jónsson Jr H, Löfberg AM, Lörelius LE, Sjöström L. Embolization of spinal metastases reduces perioperative blood loss. 21 patients operated on for renal cell carcinoma. Acta Orthop Scand 1993; 64 (1) 9-12
    CrossrefPubMedGoogle Scholar
  • 10 Gemmete JJ, Chaudhary N, Pandey A , et al. Usefulness of percutaneously injected ethylene-vinyl alcohol copolymer in conjunction with standard endovascular embolization techniques for preoperative devascularization of hypervascular head and neck tumors: technique, initial experience, and correlation with surgical observations. AJNR Am J Neuroradiol 2010; 31 (5) 961-966
    CrossrefPubMedGoogle Scholar
  • 11 Arat A, Cil BE, Vargel I , et al. Embolization of high-flow craniofacial vascular malformations with Onyx. AJNR Am J Neuroradiol 2007; 28 (7) 1409-1414
    CrossrefPubMedGoogle Scholar
  • 12 Hurley MC, Gross BA, Surdell D , et al. Preoperative Onyx embolization of aggressive vertebral hemangiomas. AJNR Am J Neuroradiol 2008; 29 (6) 1095-1097
    CrossrefPubMedGoogle Scholar
  • 13 Gemmete JJ, Patel S, Pandey AS , et al. Preliminary experience with the percutaneous embolization of juvenile angiofibromas using only ethylene-vinyl alcohol copolymer (Onyx) for preoperative devascularization prior to surgical resection. AJNR Am J Neuroradiol 2012; 33 (9) 1669-1675
    Google Scholar
  • 14 Shah HM, Gemmete JJ, Chaudhary N, Pandey AS, Ansari SA. Preliminary experience with the percutaneous embolization of paragangliomas at the carotid bifurcation using only ethylene vinyl alcohol copolymer (EVOH) Onyx. J Neurointerv Surg 2012; 4 (2) 125-129
    CrossrefPubMedGoogle Scholar
  • 15 Elhammady MS, Wolfe SQ, Ashour R , et al. Safety and efficacy of vascular tumor embolization using Onyx: is angiographic devascularization sufficient?. J Neurosurg 2010; 112 (5) 1039-1045
    CrossrefPubMedGoogle Scholar
  • 16 Tasar M, Yetiser S. Glomus tumors: therapeutic role of selective embolization. J Craniofac Surg 2004; 15 (3) 497-505
    CrossrefPubMedGoogle Scholar
  • 17 White JB, Link MJ, Cloft HJ. Endovascular embolization of paragangliomas: a safe adjuvant to treatment. J Vasc Interv Neurol 2008; 1 (2) 37-41
    PubMedGoogle Scholar
  • 18 Rangel-Castilla L, Shah AH, Klucznik RP, Diaz OM. Preoperative Onyx embolization of hypervascular head, neck, and spinal tumors. Experience with 100 consecutive cases from a single tertiary center. J Neurointerv Surg 2012; 6 (1) 51-56
    PubMedGoogle Scholar
  • 19 Duffis EJ, Gandhi CD, Prestigiacomo CJ , et al; Society for Neurointerventional Surgery. Head, neck, and brain tumor embolization guidelines. J Neurointerv Surg 2012; 4 (4) 251-255
    CrossrefPubMedGoogle Scholar
  • 20 Komemushi A, Tanigawa N, Okuda Y , et al. A new liquid embolic material for liver tumors. Acta Radiol 2002; 43 (2) 186-191
    PubMedGoogle Scholar
  • 21 Dawbarn RM. The starvation operation for malignancy in the external carotid area. JAMA 1904; 43 (12) 792-795
    PubMedGoogle Scholar
  • 22 Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 1974; 41 (2) 125-145
    CrossrefPubMedGoogle Scholar
  • 23 Gupta R, Thomas AJ, Horowitz M. Intracranial head and neck tumors: endovascular considerations, present and future. Neurosurgery 2006; 59 (5) (Suppl. 03) S251-S260 ; discussion S3–S13
    PubMedGoogle Scholar
  • 24 Manelfe C, Guiraud B, David J , et al. Embolization by catheterization of intracranial meningiomas [in French]. Rev Neurol (Paris) 1973; 128 (5) 339-351
    PubMedGoogle Scholar
  • 25 Dean BL, Flom RA, Wallace RC , et al. Efficacy of endovascular treatment of meningiomas: evaluation with matched samples. AJNR Am J Neuroradiol 1994; 15 (9) 1675-1680
    PubMedGoogle Scholar
  • 26 Deshmukh VR, Fiorella DJ, McDougall CG, Spetzler RF, Albuquerque FC. Preoperative embolization of central nervous system tumors. Neurosurg Clin N Am 2005; 16 (2) 411-432 , xi
    CrossrefPubMedGoogle Scholar
  • 27 Gruber A, Bavinzski G, Killer M, Richling B. Preoperative embolization of hypervascular skull base tumors. Minim Invasive Neurosurg 2000; 43 (2) 62-71
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Guzman R, Dubach-Schwizer S, Heini P , et al. Preoperative transarterial embolization of vertebral metastases. Eur Spine J 2005; 14 (3) 263-268
    CrossrefPubMedGoogle Scholar
  • 29 Kim LJ, Albuquerque FC, Aziz-Sultan A, Spetzler RF, McDougall CG. Low morbidity associated with use of n-butyl cyanoacrylate liquid adhesive for preoperative transarterial embolization of central nervous system tumors. Neurosurgery 2006; 59 (1) 98-104 ; discussion 98–104
    CrossrefPubMedGoogle Scholar
  • 30 Nelson PK, Setton A, Choi IS, Ransohoff J, Berenstein A. Current status of interventional neuroradiology in the management of meningiomas. Neurosurg Clin N Am 1994; 5 (2) 235-259
    PubMedGoogle Scholar
  • 31 Oka H, Kurata A, Kawano N , et al. Preoperative superselective embolization of skull-base meningiomas: indications and limitations. J Neurooncol 1998; 40 (1) 67-71
    CrossrefPubMedGoogle Scholar
  • 32 Rosen CL, Ammerman JM, Sekhar LN, Bank WO. Outcome analysis of preoperative embolization in cranial base surgery. Acta Neurochir (Wien) 2002; 144 (11) 1157-1164
    CrossrefPubMedGoogle Scholar
  • 33 Loh Y, Duckwiler GR ; Onyx Trial Investigators. A prospective, multicenter, randomized trial of the Onyx liquid embolic system and N-butyl cyanoacrylate embolization of cerebral arteriovenous malformations. Clinical article. J Neurosurg 2010; 113 (4) 733-741
    CrossrefPubMedGoogle Scholar
  • 34 Natarajan SK, Born D, Ghodke B, Britz GW, Sekhar LN. Histopathological changes in brain arteriovenous malformations after embolization using Onyx or N-butyl cyanoacrylate. Laboratory investigation. J Neurosurg 2009; 111 (1) 105-113
    CrossrefPubMedGoogle Scholar
  • 35 Elhammady MS, Peterson EC, Johnson JN, Aziz-Sultan MA. Preoperative onyx embolization of vascular head and neck tumors by direct puncture. World Neurosurg 2012; 77 (5–6) 725-730
    CrossrefPubMedGoogle Scholar
  • 36 Herman B, Bublik M, Ruiz J, Younis R. Endoscopic embolization with onyx prior to resection of JNA: a new approach. Int J Pediatr Otorhinolaryngol 2011; 75 (1) 53-56
    PubMedGoogle Scholar
  • 37 Aziz-Sultan MA, Moftakhar R, Wolfe SQ, Elhammady MS, Herman B, Farhat H. Endoscopically assisted intratumoral embolization of juvenile nasopharyngeal angiofibroma using Onyx. J Neurosurg Pediatr 2011; 7 (6) 600-603
    Google Scholar