Skip to main content
SpringerLink
Log in

Endovascular Treatment of Arteriovenous Malformations Using Ethylene Vinyl Alcohol Copolymer

  • Chapter
  • First Online:
Cerebrovascular and Endovascular Neurosurgery

Abstract

Over the past two decades, endovascular embolization has become a fundamental part of a multidisciplinary approach for the treatment of intracranial arteriovenous malformations (AVMs). Several embolic agents are now an intrinsic part of the neurointerventional armamentarium. However, none has represented as remarkable an improvement as the introduction of ethylene vinyl alcohol copolymer (EVOH). In conjunction with n-butyl cyanoacrylate (NBCA), EVOH has revolutionized the endovascular management of intracranial AVMs because of its ability to systematically deliver a sufficient volume of the embolic agent to the nidus and pedicles without extension into the venous drainage. The clinical decision to treat an AVM is facilitated by preoperative risk stratification; the first question to be addressed is whether to treat the AVM; and, if so, the second question is how to treat it. Endovascular EVOH embolization is primarily applied as an adjunct treatment to microsurgical resection or radiosurgery. Few cases are amenable to angiographic cure by embolization alone. The goal of this chapter is to describe the pertinent properties, endovascular techniques, and pitfalls for the endovascular management of intracranial AVMs using EVOH.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Abbreviations

ACA:

Anterior cerebral artery

AVM:

Arteriovenous malformation

CE:

Conformité Européenne

DMSO:

Dimethyl sulfoxide

EVOH:

Ethylene vinyl alcohol copolymer

FDA:

US Food and Drug Administration

LES:

Liquid embolic system

MCA:

Middle cerebral artery

NBCA:

n-butyl cyanoacrylate

PCA:

Posterior cerebral artery

References

  1. Crowley RW, Ducruet AF, Mcdougall CG, Albuquerque FC. Endovascular advances for brain arteriovenous malformations. Neurosurgery. 2014;74(Suppl 1):S74–82.

    Article  PubMed  Google Scholar 

  2. Taki W, Yonekawa Y, Iwata H, Uno A, Yamashita K, Amemiya H. A new liquid material for embolization of arteriovenous malformations. AJNR Am J Neuroradiol. 1990;11:163–8.

    PubMed  CAS  Google Scholar 

  3. Murayama Y, Vinuela F, Ulhoa A, Akiba Y, Duckwiler GR, Gobin YP, Vinters HV, Greff RJ. Nonadhesive liquid embolic agent for cerebral arteriovenous malformations: preliminary histopathological studies in swine rete mirabile. Neurosurgery. 1998;43:1164–75.

    Article  CAS  PubMed  Google Scholar 

  4. Jahan R, Murayama Y, Gobin YP, Duckwiler GR, Vinters HV, Vinuela F. Embolization of arteriovenous malformations with Onyx: clinicopathological experience in 23 patients. Neurosurgery. 2001;48:984–95. Discussion 995–7.

    PubMed  CAS  Google Scholar 

  5. Weber W, Kis B, Siekmann R, Kuehne D. Endovascular treatment of intracranial arteriovenous malformations with Onyx: technical aspects. AJNR Am J Neuroradiol. 2007b;28:371–7.

    PubMed  CAS  Google Scholar 

  6. Natarajan SK, Ghodke B, Britz GW, Born DE, Sekhar LN. Multimodality treatment of brain arteriovenous malformations with microsurgery after embolization with Onyx: single-center experience and technical nuances. Neurosurgery. 2008;62:1213–25. Discussion 1225–6.

    Article  PubMed  Google Scholar 

  7. Crowley RW, Ducruet AF, Kalani MY, Kim LJ, Albuquerque FC, Mcdougall CG. Neurological morbidity and mortality associated with the endovascular treatment of cerebral arteriovenous malformations before and during the Onyx era. J Neurosurg. 2015;122:1492–7.

    Article  CAS  PubMed  Google Scholar 

  8. Ozturk MH, Unal H, Dinc H. Embolization of an AVM with acrylic glue through a new microcatheter with detachable tip: an amazing experience. Neuroradiology. 2008;50:903–4.

    Article  PubMed  Google Scholar 

  9. Maimon S, Strauss I, Frolov V, Margalit N, Ram Z. Brain arteriovenous malformation treatment using a combination of Onyx and a new detachable tip microcatheter, SONIC: short-term results. AJNR Am J Neuroradiol. 2010;31:947–54.

    Article  CAS  PubMed  Google Scholar 

  10. Altschul D, Paramasivam S, Ortega-Gutierrez S, Fifi JT, Berenstein A. Safety and efficacy using a detachable tip microcatheter in the embolization of pediatric arteriovenous malformations. Childs Nerv Syst. 2014;30:1099–107.

    Article  PubMed  Google Scholar 

  11. Fifi JT. Experience with detachable tip microcatheter [online]. 2014. http://www.svin.org/files/Experiance_Fifi.pdf. Accessed Aug 2016.

  12. Herial NA, Khan AA, Sherr GT, Qureshi MH, Suri MF, Qureshi AI. Detachable-tip microcatheters for liquid embolization of brain arteriovenous malformations and fistulas: a United States single-center experience. Neurosurgery. 2015;11(Suppl 3):404–11. Discussion 411.

    Article  PubMed  Google Scholar 

  13. Herial NA, Khan AA, Suri MF, Sherr GT, Qureshi AI. Liquid embolization of brain arteriovenous malformation using novel detachable tip micro catheter: a technical report. J Vasc Interv Neurol. 2014;7:64–8.

    PubMed  PubMed Central  Google Scholar 

  14. Song D, Leng B, Gu Y, Zhu W, Xu B, Chen X, Zhou L. Clinical analysis of 50 cases of BAVM embolization with Onyx, a novel liquid embolic agent. Interv Neuroradiol. 2005;11:179–84.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Chapot R, Stracke P, Velasco A, Nordmeyer H, Heddier M, Stauder M, Schooss P, Mosimann PJ. The pressure cooker technique for the treatment of brain AVMs. J Neuroradiol. 2014;41:87–91.

    Article  PubMed  Google Scholar 

  16. Lopes DK, Bagan B, Wells K. Onyx embolization of arteriovenous malformations using 2 microcatheters. Neurosurgery. 2010;66:616–8. Discussion 618–9.

    Article  PubMed  Google Scholar 

  17. Flores BC, Klinger DR, Rickert KL, Barnett SL, Welch BG, White JA, Batjer HH, Samson DS. Management of intracranial aneurysms associated with arteriovenous malformations. Neurosurg Focus. 2014;37:E11.

    Article  PubMed  Google Scholar 

  18. Cockroft KM, Hwang SK, Rosenwasser RH. Endovascular treatment of cerebral arteriovenous malformations: indications, techniques, outcome, and complications. Neurosurg Clin N Am. 2005;16:367–80.

    Article  PubMed  Google Scholar 

  19. Ducruet AF, Crowley RW, McDougall CG, Albuquerque FC. Embolization of Cerebral Arteriovenous Malformations. In Lanzer P (ed.): PanVascular Medicine; Integrated Approach for the 21st Century. Berlin, Springer, 2015.

    Google Scholar 

  20. U.S. Food and Drug Administration. Catheter entrapment with the ev3 Onyx liquid embolic system: FDA safety communication [Online]. 2015. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm310121.htm. Archived at https://archive-it.org/collections/7993?q=Catheter+entrapment+with+the+ev3+Onyx+liquid+embolic+system&page=1&show=ArchivedPages. Accessed November 1, 2017.

  21. Katsaridis V, Papagiannaki C, Aimar E. Curative embolization of cerebral arteriovenous malformations (AVMs) with Onyx in 101 patients. Neuroradiology. 2008;50:589–97.

    Article  PubMed  Google Scholar 

  22. Pierot L, Januel AC, Herbreteau D, Barreau X, Drouineau J, Berge J, Sourour N, Cognard C. Endovascular treatment of brain arteriovenous malformations using Onyx: preliminary results of a prospective multicenter study. Interv Neuroradiol. 2005;11:159–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Reig AS, Rajaram R, Simon S, Mericle RA. Complete angiographic obliteration of intracranial AVMs with endovascular embolization: incomplete embolic nidal opacification is associated with AVM recurrence. J Neurointerv Surg. 2010;2:202–7.

    Article  PubMed  Google Scholar 

  24. Renieri L, Consoli A, Scarpini G, Grazzini G, Nappini S, Mangiafico S. Double arterial catheterization technique for embolization of brain arteriovenous malformations with Onyx. Neurosurgery. 2013;72:92–8. Discussion 98.

    Article  PubMed  Google Scholar 

  25. Van Rooij WJ, Jacobs S, Sluzewski M, Van Der Pol B, Beute GN, Sprengers ME. Curative embolization of brain arteriovenous malformations with Onyx: patient selection, embolization technique, and results. AJNR Am J Neuroradiol. 2012b;33:1299–304.

    Article  CAS  PubMed  Google Scholar 

  26. Abud DG, Riva R, Nakiri GS, Padovani F, Khawaldeh M, Mounayer C. Treatment of brain arteriovenous malformations by double arterial catheterization with simultaneous injection of Onyx: retrospective series of 17 patients. AJNR Am J Neuroradiol. 2011;32:152–8.

    Article  CAS  PubMed  Google Scholar 

  27. Gao X, Liang G, Li Z, Wang X, Yu C, Cao P, Chen J, Li J. Transarterial coil-augmented Onyx embolization for brain arteriovenous malformation: technique and experience in 22 consecutive patients. Interv Neuroradiol. 2014;20:83–90.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Loh Y, Duckwiler GR. 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;113:733–41.

    Article  PubMed  Google Scholar 

  29. de Los Reyes K, Patel A, Doshi A, Egorova N, Panov F, Bederson JB, Frontera JA. Seizures after Onyx embolization for the treatment of cerebral arteriovenous malformation. Interv Neuroradiol. 2011;17:331–8.

    Article  PubMed  Google Scholar 

  30. Gao K, Yang XJ, Mu SQ, Li YX, Zhang YP, Lu M, Wu ZX. Embolization of brain arteriovenous malformations with ethylene vinyl alcohol copolymer: technical aspects. Chin Med J. 2009;122:1851–6.

    PubMed  Google Scholar 

  31. Hauck EF, Welch BG, White JA, Purdy PD, Pride LG, Samson D. Preoperative embolization of cerebral arteriovenous malformations with Onyx. AJNR Am J Neuroradiol. 2009;30:492–5.

    Article  CAS  PubMed  Google Scholar 

  32. Lv X, Wu Z, Jiang C, Li Y, Yang X, Zhang Y, Zhang N. Complication risk of endovascular embolization for cerebral arteriovenous malformation. Eur J Radiol. 2011;80:776–9.

    Article  PubMed  Google Scholar 

  33. Pan JW, Zhou HJ, Zhan RY, Wan S, Yan M, Fan WJ, Wu ZX, Zheng SS. Supratentorial brain AVM embolization with Onyx-18 and post-embolization management: a single-center experience. Interv Neuroradiol. 2009;15:275–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Panagiotopoulos V, Gizewski E, Asgari S, Regel J, Forsting M, Wanke I. Embolization of intracranial arteriovenous malformations with ethylene-vinyl alcohol copolymer (Onyx). AJNR Am J Neuroradiol. 2009;30:99–106.

    Article  CAS  PubMed  Google Scholar 

  35. Rodriguez-Boto G, Gutierrez-Gonzalez R, Gil A, Serna C, Lopez-Ibor L. Combined staged therapy of complex arteriovenous malformations: initial experience. Acta Neurol Scand. 2013;127:260–7.

    Article  CAS  PubMed  Google Scholar 

  36. Saatci I, Geyik S, Yavuz K, Cekirge HS. Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course. J Neurosurg. 2011;115:78–88.

    Article  PubMed  Google Scholar 

  37. Soltanolkotabi M, Schoeneman SE, Alden TD, Hurley MC, Ansari SA, Dipatri AJ Jr, Tomita T, Shaibani A. Onyx embolization of intracranial arteriovenous malformations in pediatric patients. J Neurosurg Pediatr. 2013;11:431–7.

    Article  PubMed  Google Scholar 

  38. Van Rooij WJ, Jacobs S, Sluzewski M, Beute GN, Van Der Pol B. Endovascular treatment of ruptured brain AVMs in the acute phase of hemorrhage. AJNR Am J Neuroradiol. 2012a;33:1162–6.

    Article  CAS  PubMed  Google Scholar 

  39. Van Rooij WJ, Sluzewski M, Beute GN. Brain AVM embolization with Onyx. AJNR Am J Neuroradiol. 2007;28:172–7. Discussion 178.

    Article  CAS  PubMed  Google Scholar 

  40. Weber W, Kis B, Siekmann R, Jans P, Laumer R, Kuhne D. Preoperative embolization of intracranial arteriovenous malformations with Onyx. Neurosurgery. 2007;61:244–52. Discussion 252–4.

    Article  PubMed  Google Scholar 

  41. Frizzel RT, Fisher WS III. Cure, morbidity, and mortality associated with embolization of brain arteriovenous malformations: a review of 1246 patients in 32 series over a 35-year period. Neurosurgery. 1995;37:1031–9. Discussion 1039–40.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank the editorial staff of the Neuroscience Publications office of Barrow Neurological Institute for their invaluable assistance with the production of this chapter, without whom this work would not have been possible.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

    Bruno C. Flores M.D. & Bradley A. Gross M.D.

  2. c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

    Felipe C. Albuquerque M.D.

Authors
  1. Bruno C. Flores M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bradley A. Gross M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Felipe C. Albuquerque M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Felipe C. Albuquerque M.D. .

Editor information

Editors and Affiliations

  1. Department of Neurosurgery, Westchester Medical Center/NY Medical College, Valhalla, New York, USA

    Chirag D. Gandhi

  2. Department of Neurological Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA

    Charles J. Prestigiacomo

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Cite this chapter

Flores, B.C., Gross, B.A., Albuquerque, F.C. (2018). Endovascular Treatment of Arteriovenous Malformations Using Ethylene Vinyl Alcohol Copolymer. In: Gandhi, C., Prestigiacomo, C. (eds) Cerebrovascular and Endovascular Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-319-65206-1_29

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-65206-1_29

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-65204-7

  • Online ISBN: 978-3-319-65206-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation