Endovascular Embolization of Intracranial Infectious Aneurysms in Patients Undergoing Open Heart Surgery Using n-Butyl Cyanoacrylate

Abstract

Introduction: Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. Methods: Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. Results: Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. Conclusions: Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.

Endovascular therapy for intracranial infectious aneurysms associated with a left ventricular assist device: illustrative case

“…Endovascular therapy for IIAs has a high success rate and safety of endovascular embolization with NBCA for IIAs in patients undergoing open-heart surgery and exposed to anticoagulants. 12 Theoretically, placing foreign materials, including coils and liquid embolization agents, into an infected vessel could extend the infection and result in brain abscess or meningitis. Moreover, it is a concern that neurointerventional treatment using embolization substance for IAAs of patients with an LVAD has a higher risk of the focal infection of the cerebral vessel persisting or worsening than patients without LVAD because an infected LVAD remains in the body.…”

Intracranial Mycotic Aneurysm after Left Ventricular Assist Device Implantation Treated with Trans-arterial Embolization via the Brachial Artery: A Case Report

“…Generally, liquid embolic agents were used instead of coils to treat distally located intracranial mycotic aneurysms because of their simultaneous sealing of lesions and deliverability of microcatheters to these distal lesions. 19) According to previous reports, NBCA 20) and ethylene-vinyl alcohol copolymer (Onyx, eV3 Neurovascular, Irvine, CA, USA) 21) were used for the treatment of distally located intracranial mycotic aneurysms. Owing to the poor general condition of patients with LVAD placement, including their cardiac function, NBCA might be considered more suitable than Onyx, as a liquid embolic agent; it does not require induction of general anesthesia, thereby avoiding adverse effects of general anesthesia.…”

Cerebrovascular Complication and Valve Surgery in Infective Endocarditis

“…There have been many reports of efficacy of endovascular treatment of IIA, using either coiling or embolic agents. [62][63][64][65][66][67] There are multiple techniques involved in EVT, including both indirect and direct approaches. The indirect approach involves parent artery occlusion using coil or liquid embolic agents (such as N-butylcyanoacrylate or Onyx), and are typically employed for IIA in a distal location, dysplastic/complex morphology, circumferential involvement of the parent vessel, or location in noneloquent cortex.…”