Novel Use of Onyx Liquid Embolic System for Treatment of Traumatic Internal Carotid Artery Transection J. Kraus, MD
1,2 PhD ,
1 MD ,
of Neurological Surgery and 2Department of Radiology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ
RATIONALE: Penetrating neck injury causing internal carotid artery (ICA) vascular tears or complete transection are nearly always fatal.1 These life-threatening vascular injuries often present with exsanguinating hemorrhage and may later develop global anoxic brain injury with cerebral ischemia, brain herniation and death. Resuscitation is complicated by the need for emergent surgical control of the ICA.2
METHODS: 1. Emergent angiography showed brisk contrast extravasation from the right cervical ICA without flow distal to the lesion, demonstrating complete ICA transection.
3. Precise endovascular repair of a long segment of the transected ICA was achieved using Onyx material. A Marathon (2.7/1.3-Fr x 165 cm) microcatheter and X-pedion (0.010â€?) was used in delivering 0.7 cc of Onyx-34 that was injected at a rate of 1cc/min. into the right ICA.
RESULTS: 1. The right ICA was occluded without Onyx extrusion.
Management recommendations are controversial. Open surgical exploration with ligation repair is limited by the ability to achieve safe and rapid access in patients with severe hypotension and massive hemorrhage into the field. The accepted surgical management paradigm is undergoing modification as minimally invasive endovascular repairs become increasingly safe, costeffective and available.
Traumatic ICA transection is a well-described sequelae of penetrating neck and facial injury. Such injuries are associated with a high mortality rate that ranges in the literature from 70 % to 100%.3 Delays in precise diagnosis and definitive treatment can be fatal for the patient. Parent vessel sacrifice is often necessary and has been utilized for centuries. Recently, endovascular treatments using detachable balloons or coils have begun to supplant more invasive approaches. 4,5 We have demonstrated another possible endovascular approach to treating ICA transection using Onyx, a liquid embolic material. Onyx is an embolic agent commonly used to treat arteriovenous malformations and is also approved for use as a Humanitarian Use Device for certain intracranial aneurysms.
PROBLEM: A 35 year-old man with a GSW to the face and neck presented pulseless, hypotensive and acidotic. ACLS was initiated with return of a perfusing rhythm. Restoration of blood pressure resulted in exsanguination from the oro-and nasopharynx despite maximal packing. Imaging showed multiple facial fractures, possible cervical ICA occlusion and no acute cerebral injury.
1. We report the novel use of Onyx-34 for rapid Figure 2. Right common carotid artery (CCA) angiogram lateral view demonstrating complete occlusion of the mid cervical segment of the right internal carotid artery . Notice the extravasation of contrast that signifies active bleeding.
2. Pre-embolization assessment of flow to the ipsilateral hemisphere showed significant collateral blood supply.
and complete hemostasis of a transected ICA Figure 4. Right common carotid artery (CCA) angiogram lateral view status post 0.7 ml of onyx embolization. There was complete obliteration of the cervical segment of the right internal carotid artery distal to the origin.
resulting from a GSW to the face and neck. 2. Onyx-34 was delivered precisely, achieved rapid ICA occlusion, preserved the CCA and
2. Post-embolization assessment of flow to the ipsilateral hemisphere showed significant collateral blood supply.
thus critical ipsilateral ECA:ICA anastamoses. 3. Onyx was not seen to extrude into the CCA, ECA, distal ICA or surrounding tissues. REFERENCES: 1. Nanda A, Vannemreddy PS, Willis BK, Baskaya MK, Jawahar A. Management of carotid artery injuries: Louisiana State University Shreveport experience. Surg Neurol. 2003; 59: 184-190. 2. Rostomily RC, Newell DW et.al. Gunshot wounds of the internal carotid artery at the skull base: management with vein bypass grafts and a review of the literature. J Trauma 1997; 42 (1): 123-132. 3. Zhong QJ, Xiao YB, Peng L, Hao J, An Y, Ma RY. Surgical treatment for traumatic transection of left common carotid artery. Chin J Traumatol 2005; 8 (3): 191-192.
Figure 1 Skull base CT scan with contrast showing decreased caliber of the right internal carotid artery that may be due to dissection or thrombosis.
Figure 3. External carotid artery angiogram late arterial phase showing retrograde filling of the distal ICA via the ophthalmic artery (arrow).
Figure 5.Right vertebral artery angiogram lateral views status post onyx embolization. This angiogram demonstrates good collateral flow to the right middle cerebral artery and right anterior cerebral artery via a patent posterior communicating artery (arrow).
4. McNeil JD, Chiou AC, et.al. Successful endovascular therapy of a penetrating zone III internal carotid injury. J Vasc Surg 2002; 36 (1):187-190. 5. Weber W. Endovascular treatment of intracranial arteriovenous malformations with Onyx: technical aspects. AJNR 2007; 28: 371-377.