Pre-operative direct puncture embolization of head and neck hypervascular tumors using SQUID 12

Abstract

Objective: The authors have evaluated their experience in pre-operative direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12, an embolic liquid agent.

Methods: Between July 2016 and March 2019, the authors retrospectively reviewed clinical, embolization and surgical data of 11 consecutive patients with 12 hypervascular head and neck tumors who had undergone pre-operative embolization using SQUID 12. Percutaneous embolizations were performed by inserting a 19-22 Gauge needle directly into the tumor under ultrasound, fluoroscopic and/or endoscopic guidance. The hub of the needle was connected to a 15-cm DMSO-compatible extension tube, and the SQUID 12 was injected.

Results: Total or near-total devascularization was achieved in 11 over 12 cases. Complete en-bloc tumor removal by surgery was achieved in all cases. Only one patient required blood transfusion. No major periprocedural adverse events were recorded.

Conclusions: Direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12 seems to be safe and effective. It may offer almost complete devascularization due to homogenous, deep penetration in the tumor, with optimal visibility of the agent throughout the percutaneous procedure. It may reduce intraoperative blood loss and the need for transfusion, thus facilitating complete surgical resection.

Keywords: Head and neck; embolization; image-guided procedures; innovative biotechnologies; liquid embolic agents.

Figure 1.

A left carotid paraganglioma in a 78-year-old patient. (a) and (b): left CCA angiogram showing the hypervascular nature of the tumor widening the carotid bifurcation and fed by hypertrophic vessels arising from branches of the ECA. (c) After inflation of the balloon in the ECA distal to the origin of the superior thyroid artery, multiple other tiny feeders are shown arising at the origin of the ECA itself. (d) For this reason, the balloon was replaced and inflated at the very origin of the ECA in order to avoid any unwanted reflux of the embolic agent. (e) Intra-tumoral angiogram obtained by direct puncture of the mass. (f) Control angiogram during embolization with SQUID 12 (balloon still inflated in the ECA). (g) Final angiogram after deflation of the balloon, showing the complete devascularization of the lesion. (h) and (i) Surgical procedure after pre-operative embolization with complete resection of the tumor fully filled with SQUID 12. CCA: common carotid artery; ECA: external carotid artery.

Figure 2.

A juvenile angiofibroma in a 17-year-old boy. (a) Sagittal contrast-enhanced T1-weighted MR showing a contrast-enhancing tumor within the left nasal cavity extending posteriorly into the nasopharynx. (b) Left internal and (c) external subtracted angiograms demonstrating a hypervascular mass fed by multiple arterial branches of external carotid artery and a small artery arising from a petrous portion of the internal carotid. Lateral radiogram (d) showing a 19-Gauge needle inserted within the tumor by trans-nasal means. (e) Post-embolization lateral radiogram and (f) subtracted angiograms showing the SQUID 12 cast and the complete devascularization of the tumor.

Figure 3.

A right vagal paraganglioma in a 34-year-old patient. (a) Sagittal reformatted CTA image showing a large vagal paraganglioma extending upward to the skull base; (b) Lateral view of right CCA angiogram showing the hypervascular nature of the tumor displacing both the ICA and ECA anteriorly, fed by multiple branches of the ECA; (c) anterior view of intra tumoral angiogram obtained by means of the direct puncture of the mass; (d) Anterior view of right CCA control angiogram showing the hypervascular tumor (widening the carotid bifurcation) and the correct position of the needle within the mass; (e) Anterior and lateral (f) views of right CCA angiogram showing the complete devascularization of the tumor at the end of the embolization procedure by direct puncture injection of SQUID 12. CCA: common carotid artery; ICA: internal carotid artery; ECA: external carotid artery.