A safer endovascular technique for pre-operative embolization of juvenile nasopharyngeal angiofibroma: avoiding the pitfalls of external carotid artery – internal carotid artery anastomoses

Abstract

Intra-arterial embolization of juvenile nasopharyngeal angiofibroma (JNA) prior to surgical resection is the preferred approach to minimize blood loss during surgical resection of the tumor. However, the presence of external carotid artery–internal carotid artery (ECA-ICA) anastomoses may hinder complete tumor embolization due to the associated risk for embolic complications. Here, we evaluate the use of a balloon-assisted embolization (BAE) technique in the treatment of JNA. We conducted a retrospective review of JNA patients who underwent tumor embolization with injection of Onyx in a single session between 2013-2018. All cases displayed tumor arterial supply from ECA and ICA circulations on 2-D catheter angiograms. Procedural and surgical outcome data were analyzed. Results are given as mean±- standard deviation (range). Among 9 patients with JNA, all were males and mean age was 14.1±6.3 years (range, 9-29 years). The mean tumor volume embolization was 84.4±12.4% (range, 60-100%) and in 89% patients ≥80% of tumor volume embolization was achieved. There were no embolization-related complications reported. During surgical resection of the tumor there was a low average surgical blood loss of 722±651.5 mL (range, 50-2,000 mL) and the mean procedure time was 282.6±85.4 mins (range, 151-403 mins). In this series, the BAE technique showed to be a safe and effective approach to achieve successful tumor embolization while avoiding embolic complications and effectively reducing the risk for blood loss during surgical resection.

Preoperative Embolization of Fisch Grades II–IVa Juvenile Nasopharyngeal Angiofibromas: Transarterial Embolization in the Age of Onyx

“…Elhammady et al utilized the same ImageJ software to determine the percentage of devascularization describes a 77%-93% mean obliteration rate after endovascular treatment of 10 patients with Onyx, which is comparable to our results [16]. Rosenbaum-Halevi et al also describe a case series of nine patients that underwent pre-resection JNA embolizations with Onyx with a mean tumor volume embolization/devascularization of 84%, which is also similar to our results [19]. Thus, Onyx is shown to be an effective agent yielding high percentages of devascularization of tumors without a high risk of complications or neurological injury.…”

“…Elhammady et al demonstrated that embolization of these tumors can be done efficiently with a direct puncture with a decreased fluoroscopy time, better tumor devascularization, and decreased estimated blood loss [16]. Rosenbaum-Halevi et al demonstrated efficient embolization of JNAs through dual access of both the ECA and the internal carotid artery (ICA) [19]. A 6F catheter was placed in the ECA with subsequent injection of Onyx 34 into the tumor vessel while a balloon catheter was inflated in the ICA to prevent inadvertent embolization of normal vessels and travel of embolic material into the intracranial circulation [19].…”

“…Rosenbaum-Halevi et al demonstrated efficient embolization of JNAs through dual access of both the ECA and the internal carotid artery (ICA) [19]. A 6F catheter was placed in the ECA with subsequent injection of Onyx 34 into the tumor vessel while a balloon catheter was inflated in the ICA to prevent inadvertent embolization of normal vessels and travel of embolic material into the intracranial circulation [19].…”

Single-Center Experiences of Preoperative Juvenile Nasal Angiofibroma Embolization With Gelfoam, Reducing Financial Burden on Patients in Developing Country

“…During an initial diagnostic angiogram, JNAs that show external carotid-internal carotid anastomoses are recommended to be embolized by some modified techniques like using microcatheter, preferring liquid embolic agent over particulate agents, or adopting balloon-assisted embolization for the safety of the procedure. Otherwise, there is a risk of intracranial migration of particles resulting in serious neurological complications like stroke and vision loss [15][16][17][18][19][20][21].…”

Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate

“…Preoperative embolization is used for virtually all cases of JNA, resulting in reduction in intraoperative bleeding, occlusion of surgically inaccessible arterial feeding vessels, decreased operative time and improved surgical visualization, identification and protection of adjacent structures [4][5][6]. This results in a significant reduction in overall surgical complications and, despite some reports of safe resection without embolization, it is considered to be the standard of care in most centers [7][8][9]. In this study, we describe our single-center experience in preoperative JNA devascularization with the injection of polyvinyl alcohol (PVA) into major lesion feeders, highlighting the safety and efficacy of this technique.…”