Embolization of an arteriovenous malformation using the "pressure cooker" technique in the AICA via a marathon microcatheter: A case report.

INTRODUCTION AND IMPORTANCE: Embolization of an arteriovenous malformation (AVM) via the anterior inferior cerebellar artery (AICA) is difficult. The "pressure cooker" technique in the AICA via a marathon microcatheter can be effective. CASE STUDY: A 43-year-old man with a cerebellar hematoma involving the brainstem. Angiography revealed an AVM supplied by the right AICA. Embolizing the AVM by casting an Onyx-18 liquid embolic system assisted by the "pressure cooker" technique was planned. An Apollo microcatheter was used for Onyx casting, and a Marathon microcatheter was used to establish a coiling plug to prevent Onyx reflux. The AVM was obliterated. Postoperatively, burr hole drainage of the cerebellar hematoma was performed. Postoperative computed tomography showed that the cerebellar hematoma and hydrocephalus had resolved. Magnetic resonance imaging revealed that there was no new serious infarction from damage to the cerebellum or brainstem. The patient recovered well. CLINICAL DISCUSSION: During Onyx casting, the drawback is that reflux can occlude normal vessels. The "pressure cooker" technique was useful for preventing Onyx reflux and for driving the Onyx to penetrate the AVM. However, it was difficult to use this technique in slim AICA; the Marathon microcatheter had a thinner tip than other microcatheters, and it can be used to establish the "pressure cooker" technique. This technique provides more solutions for AVMs in transarterial embolization through small feeding arteries. CONCLUSION: In a selective case, it was feasible to use the "pressure cooker" technique in the AICA via a Marathon microcatheter to embolize the AVM.

Application of the pressure cooker technique for transarterial embolization of brain arteriovenous malformations: Factors affecting obliteration and outcomes.

Objective: The typical pressure cooker technique (PCT) and several modifications with similar mechanisms have been introduced to enhance the embolization of brain arteriovenous malformations (bAVMs). This study aimed to assess the effectiveness of transarterial embolization of bAVMs with the PCT. Method: From January 2019 to December 2021, 125 consecutive patients with bAVM managed by transarterial embolization in the prospective database on cerebral vascular diseases of a single center were retrospectively reviewed. Patient data and lesion characteristics were collected. According to the treatment strategy, the patients were assigned to the PCT group (46 patients) and conventional embolization technique (CET) group (79 patients). Results: Baseline patient features were comparable between the two groups. After the first procedure, complete obliteration immediately was observed in 61 and 42% of patients in the PCT and CET groups, respectively. The rate was markedly elevated in the PCT group (p = 0.04). In subgroup analysis, the rate of immediate complete obliteration was starkly increased in PCT group patients with Spetzler-Martin grade I/II bAVM (86 and 53% in the PCT and CET groups, respectively; p = 0.0036). The overall complication rates were similar in the two groups (13 and 10% in the PCT and CET groups, respectively; p = 0.77). In multivariable analysis, nidus size >3 cm (OR = 8.826, 95% CI: 1.250-62.312; p = 0.03) and deep location (OR = 8.576, 95% CI: 1.480-49.690; p = 0.02) were significant factors affecting complete obliteration in the PCT group. Conclusion: The PCT may yield a higher rate of immediate complete obliteration with transarterial embolization of bAVMs, without increasing the rate of procedure-related complications.

Safety and Effectiveness of First-line Endovascular Management of Low-Grade Brain Arteriovenous Malformations : Single Center Experience in 145 Patients.

PURPOSE: Spetzler-Martin grade (SMG) I-II (low-grade) brain arteriovenous malformations (BAVMs) are often considered safe for microsurgical resection; however, the role of endovascular treatment (EVT) remains to be clarified in this indication, especially for unruptured BAVMs. The purpose of our study was to assess the safety and effectiveness of endovascular treatment as the first-line treatment for low-grade BAVMs. METHODS: From our local database, we retrospectively retrieved patients with low-grade BAVMs, either ruptured or unruptured, treated by embolization as first-line treatment in our department between January 2005 and January 2020. The primary endpoint was the total obliteration rate of BAVMs, and secondary endpoints were hemorrhagic complications and final clinical outcome, assessed through shift of the modified Rankin scale, and mortality rate secondary to BAVM embolization. RESULTS: A total of 145 patients meeting inclusion criteria and treated by EVT as first-line therapy were included in the study (82 ruptured and 63 unruptured BAVMs). Overall, complete exclusion of BAVMs was achieved in 110 patients (75.9%); 58 patients (70.7%) with ruptured and 52 (82.5%) unruptured BAVMs, including 37.9% BAVMs excluded by EVT alone (35.5% among ruptured and 44.4% among unruptured BAVMs) and 38% by combined treatment (EVT and surgery or EVT and SRS). There was no BAVM volume cut-off predictive for total obliteration by embolization alone. Early minor hemorrhagic complications were reported in 14 patients (9.6%) and early major hemorrhagic complications were reported in 5 patients (3.4%). No late hemorrhagic complications (0%) occurred; mortality rate was 0.7% (1/145 patients). Improved/unchanged mRS was reported in 137 patients (94.5%). CONCLUSION: Endovascular treatment alone or associated with others exclusion techniques, might be safe and effective for complete exclusion of low-grade brain arteriovenous malformations regardless of the volume.

Simplified pressure cooker technique for the treatment of brain AVMs, dAVFs and facial vascular malformations.

In 2014, Chapot et al. introduced the pressure cooker technique (PCT), conceived to control undesired reflux of the embolic agent during the treatment of brain arterio-venous malformations (bAVMs). Since then, this technique increased in popularity and it has been extensively used. We present five consecutive cases in which the original PCT was simplified using nylon coils instead of platinum coils and acrylic glue, hence the name of 'Simplified Pressure Cooker Technique' (sPCT). The aim was to obtain a safer, precise and faster creation of the plug to control cohesive embolic agent reflux during the treatment of brain and facial vascular malformations.

First Experience in the Control of the Venous Side of the Brain AVM.

BACKGROUND AND PURPOSE: Brain arteriovenous malformations (AVM) are increasingly curable with endovascular embolization. This study examines the preliminary experience with a novel double-sided hybrid approach in the treatment of cerebral arteriovenous malformations (AVM) versus a purely single-sided intra-arterial approach. MATERIALS AND METHODS: The single-center study cohort included 18 patients with brain AVMs (Spetzler-Martin Grade 2 or 3) having stand-alone endovascular treatment with either the arterial-side-only pressure cooker technique (aPCT) (group 1; n = 9) or a double-sided hybrid intra-arterial and transvenous approach (HIPRENE) (group 2; n = 9). RESULTS: Patients belonging to group 2 had lower rates of intra-procedural hemorrhaging (66.7% vs. 33.3%, p = 0.169) and needed fewer treatment sessions to achieve nidus occlusion (1.7 vs. 1.2, p = 0.136). The HIPRENE treatment regime led to higher nidus occlusion rates after the initial treatment compared to aPCT (77.7% vs. 44.4%, p = 0.167). Group 2 patients had a lower rate of neuromonitoring events (22.2% vs. 44.4%, p = 0.310) and fewer accounts of blood flow obstruction in post-operative MRIs (33.3% vs. 55.6%, p = 0.319). CONCLUSION: A double-sided hybrid intra-arterial and transvenous approach might have benefits for curative endovascular brain AVM treatment in patients with Spetzler-Martin Grade 2 or 3. In our small study cohort, the HIPRENE treatment regime had higher nidus occlusion rates after the first treatment, which reduces the number of treatment sessions and lowers intra- and post-operative complication rates. Further randomized controlled studies are awaited to corroborate our preliminary outcomes.

Meningioma embolization with the pressure cooker technique using Squid 12.

Background Preoperative meningioma embolization may be performed with microparticles or liquid embolic agents. The pressure cooker technique (PCT) has recently been described for the embolization of brain arteriovenous malformations (AVMs). Case We present the case of a 73-year-old woman with a large frontal interhemispheric meningioma that was successfully preoperatively embolized with the PCT using Squid 12, a new ethyl-vinyl alcohol copolymer embolic agent. The PCT presents considerable advantages relative to conventional embolization techniques such as deeper and faster tumor penetration and embolization of tumors with difficult vascular access, and retrograde feeling of pial afferents may be achieved. Conclusions The use of the PCT with Squid 12 may potentially increase the effectiveness of meningioma embolization, increase tumor devascularization and improve outcomes of surgical resection.

The transvenous pressure cooker technique: A treatment for brain arteriovenous malformations.

The treatment of brain arteriovenous malformations (AVMs) remains a significant challenge, especially hemorrhagic AVMs which are unsuitable for microsurgery or radiosurgery. We demonstrate an AVM located in the left basal ganglia area, supplied by slender arteries, and treated by the transvenous pressure cooker technique. Herein, we describe the procedure and outline the crucial points and indications for this technique.

Embolization of dural arteriovenous fitula at the petrous apex region with pressure cooker technique / 中国脑血管病杂志

Objective To investigate the operation key points and therapeutic effect using the pressure cooker technique (PCT)for embolization of the dural arteriovenous fistula (DAVF)at the petrous apex region. Methods The clinical data of 4 patients with DAVF at the petrous apex region admitted to the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University from October 2015 to February 2016 were analyzed retrospectively. The PCT technique was used to conduct embolization therapy. Results DSA confirmed that 4 patients had DAVF at the petrous apex region with the multi-branch artery blood supply and they were drained via the superior petrosal veins. The patients were embolized by using PCT. DSA confirmed that they were embolized completely after procedure. They were followed up at 3months after surgery and their symptoms were improved. Conclusion For DAVF at the petrous apex region with the multi-branch artery blood supply,the preliminary experience shows that PCT technique may improve the efficiency of embolization,thereby obtaining anatomical cure.

Pressure cooker technique for curative embolization of intracranial arteriovenous malformation / 中国脑血管病杂志

Objective To preliminarily discuss the technical points and clinical efficacy of the pressure cooker technique (PCT)for embolization of intracranial arteriovenous malformation (AVM). Methods From April 2015 to May 2015,7 patients with AVM were treated at the Department of Neurosurgery, Shanghai Deji Hospital. The AVMs of 2 patients were embolized with PCT. (both were Spetzler-Martin gradeⅡ). A sonic and an echelon microcatheter were implanted side by side into the same blood supply artery of an AVM. A coil + α-isobutyl cyanoacrylate (NBCA)plug was formed between the sonic microcatheter tip and the detachable point through the echelon microcatheter in order to prevent Onyx reflux when the glue was injected into a nidus via a sonic microcatheter,achieving the embolization effect of sustained,rapid and high efficient. Results Two patients achieved complete embolization immediately. The symptoms of the patients improved or disappeared within 1 month. The whole brain DSA showed the AVM of one patient did not have recurrence at 4 month after embolization. Two patients did not have any complications or sequelae at the follow-up study. Conclusion PCT can improve the efficiency of embolization. It is suitable for small, medium,superficial,non-major functional area,less feeding artery AVMs,and AVMs with less blood flow in nidus. Its safety and clinical effect still need to be observed with more samples.