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. 2005 Oct 5;11(Suppl 1):131-40.
doi: 10.1177/15910199050110S117. Epub 2005 Oct 27.

Basics and Principles in the Application of Onyx LD Liquid Embolic System in the Endovascular Treatment of Cerebral Arteriovenous Malformations

R Siekmann  1
Affiliations

Basics and Principles in the Application of Onyx LD Liquid Embolic System in the Endovascular Treatment of Cerebral Arteriovenous Malformations

R Siekmann. Interv Neuroradiol. .
No abstract available

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Figures

Figure 1
Figure 1
A) Intranidal positioning of the Microcatheter, Marathon™, in a small AVM of the left trigonum in an oblique projection and superselective injection of contrast media. B-D) Angiogram of the right vertebral artery in an early and later arterial (B,C) and venous phase (D) in the same projection, demonstrating the small arterial feeders and nidus with moderate flow and the main venous draining vein into the left sinus transversus.
Figure 2
Figure 2
Results of Onyx 20 injection in a hydraulic pump model with a simulated arterial flow of 60 ml/min. The "nidus" is in a tube consisting of compressed foam and extends within the length marked by the needles (40 mm). A) "Intranidal" positioning of the Microcatheter, Ultraflow, in the proximal part of the foam with little reflux and homogenous filling of the entire "nidus". B) Postioning of the same microcatheter just below the level of the "nidus" with huge reflux and filling up only half of the foam.
Diagram 1
Diagram 1
Results of different injection techniques (continuous versus plug&push technique) and microcatheter positions below (proximal) and within the "nidus" (nidal). Satisfactory result only after intranidal postioning and using the plug and push technique. The over one hundred percent filling in this experimental work using the rete mirabile of the swine as a biological AVM model is explained by ongoing further embolization of the contralateral part of the rete.
Diagram 2
Diagram 2
Demonstration of the increase of pressure inside the microcatheter A) after a length of reflux over 3 cm, B) and dependance on the injection speed and viscosity of Onyx.
Diagram 3
Diagram 3
Different results of the filling of the rete mirabile in swine regarding the length of reflux. Beyond a length of 2 cm there is no significant increase of filling.
Figure 3
Figure 3
Two demonstrations of a homogeneous spongic cast after embolization of AVMS, both in ap and lateral projections. A) Same patient as in Figure 1. Cast after injection 0.9 ml of Onyx 20 after single catherization and 90% angiographic occlusion of the AVM. B) Another patient with a giant temporal AVM on the left side. Cast after injection of 26 ml of Onyx in five sessions using Onyx of different viscosities and 90% occlusion of the AVM. After embolization and surgical resection the patient was clinically asymptomatic.
Figure 4
Figure 4
Summary and illustration of the decision process during the Onyx injection from the beginning of the application in repeat and reinject cycles.
Diagram 4
Diagram 4
Different times of breaks (waiting time) after the Onyx injection period from zero to 5 minutes and the influence on the pressure inside the microcatheter clearly demonstrates that beyond 3 min, there is an immense increase of the pressure and with it risk of unintentional microcatheter occlusion. Two minutes maximum is recommended in the Instructions For Use.
Diagram 5
Diagram 5
Differences between Ultraflow™ and Marathon™ regarding the soft and nitinol braided distal tip due to the detachment force (A) and the tensile strength (B). A) Comparison of the forces necessary to retrieve the microcatheters out of a cast with a reflux of 3 cm demonstrating that the detachment force in the braided one is 25% less. B) The distal tensile strength is one third greater in the braided one and demonstrates the increase stretch resistance of the distal, soft part of the microcatheter. This allows more tension to be brought to the tip and with it to pull out the catheter with more ease out of the cast.
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