J Cerebrovasc Endovasc Neurosurg.  2020 Jun;22(2):97-105. 10.7461/jcen.2020.22.2.97.

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

• Rosenbaum-Halevi D
• Lopez-Rivera V
• Turkmani A
• Sanzgiri A
• Zeineddine HA
• Luong A
• Chen PR

• KMID: 2503823
• DOI: http://doi.org/10.7461/jcen.2020.22.2.97

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.

Keyword

Juvenile nasal angiofibroma; Embolization; Surgical resection; Anastomosis; Balloon-assisted; Technique

Figure

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  Fig. 1 Illustration demonstrating example of catheter and balloon placement prior to (A) and after (B) infusion of Onyx in tumor feeders resulting in complete embolization of tumor vasculature. Black arrow: The 5×30 mm Hyperglide™ balloon in the ICA is inflated, thus protecting the C2-C4 segments of the ICA and their branches (single, double arrow heads). White arrow: Scepter™ balloon is inflated in ECA for selective Onyx-34 injection. Curved arrow: Duo™ microcatheter loaded with an 0.10 microwire to be inserted into arterial feeder of interest using the proximal end of balloon to assist in guiding wire into arterial trunk. ICA, internal carotid artery; ECA, external carotid artery.

• 

  Fig. 2 Demonstrative case, Part 1: (A) Pre-embolization subtracted angiogram of left ICA and left ECA circulations (coronal and sagittal views) shows a large left posterior nasal cavity tumor measuring 43.5 mm×44.1 mm×55.7 mm with a blood supply from distal branches of the left sphenopalatine artery, left accessory meningeal artery, left middle meningeal artery, left inferior lateral trunk, and left vidian artery. (B) Embolization of ECA feeders (balloon inflated but not visualized). (C) Unsubtracted angiogram showing Onyx cast with evidence of deep penetration to peripheral feeders. (D) Subtracted angiogram of ICA after ECA embolization shows persistent vascularization supplied by vidian artery. (E) Roadmap showing microcatheter in distal vidian artery protected by balloon. (F) Embolization of Vidian artery feeders under balloon protection. (G) Post-embolization subtracted angiogram shows reduction of tumor blush by >90%. ICA, internal carotid artery; ECA, external carotid artery.

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  Fig. 3 Demonstrative case, Part 2: (A) Pre-embolization subtracted angiogram after ICA injection demonstrates recurrent tumor supplied by inferior lateral trunk. (B) Roadmap showing placement of microcatheter in distal inferior lateral trunk with ICA balloon inflated for protection. (C) Post-embolization subtracted ICA injection shows blush reduction of 90% and abrupt cut-off of inferior lateral trunk flow to tumor. ICA, internal carotid artery.

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