Head and Neck Hypervascular Lesions: Embolization with Ethylene Vinyl Alcohol Copolymer—Laboratory Evaluation in Swine and Clinical Evaluation in Humans

PURPOSE:(a) To assess in swine long-term (12-month) histopathologic changes, particularly, those related to recanalization and angiotoxicity after endovascular delivery of ethylene vinyl alcohol copolymer (EVAC), and (b) to evaluate initial clinical experience in 18 patients with head and neck tumors and arteriovenous malformations.

MATERIALS AND METHODS: Embolization with EVAC was performed in one rete each in five swine. After 12 months, an angiogram was obtained, and the contralateral rete was also embolized (acute). Swine were sacrificed and the retia harvested for pathologic examination. In the clinical study, 18 patients with tumors (n = 14), facial arteriovenous malformations (n = 3), and vertebral arteriovenous fistula (n = 1) underwent therapeutic embolization. The technical aspects of EVAC embolization, percentage of occlusion, and clinical complications were evaluated.

RESULTS: Angiographic 12-month follow-up in swine revealed persistent occlusion of the embolized rete or retia. Histologic examination of the same rete showed vascular occlusion and moderate intraluminal foreign body giant cell reaction; the acutely embolized rete showed no endothelial denudation or angionecrosis. Clinical evaluation in patients revealed satisfactory penetration of lesion vasculature with EVAC when the microcatheter was advanced within 2 cm of a lesion or when percutaneous puncture was performed. There were two transient complications: one increase in a preexisting fifth nerve palsy and one increase in preexisting hemiparesis.

CONCLUSION: EVAC is a promising liquid embolic material providing long-term occlusion of blood vessels.


  • 1 Olerud C, Jonsson HJ, Lofberg AM, Lorelius LE, Sjostrom L. Embolization of spinal metastases reduces peroperative blood loss: 21 patients operated on for renal cell carcinoma. Acta Orthop Scand 1993; 64:9-12. Crossref, MedlineGoogle Scholar
  • 2 Tampieri D, Leblanc R, Terbrugge K. Preoperative embolization of brain and spinal hemangioblastomas. Neurosurgery 1993; 33:502-505. Crossref, MedlineGoogle Scholar
  • 3 Wakhloo AK, Juengling FD, Velthoven VV, Schumacher M, Hennig J, Schwechheimer K. Extended preoperative polyvinyl alcohol microembolization of intracranial meningiomas: assessment of two embolization techniques. AJNR Am J Neuroradiol 1993; 14:571-582. MedlineGoogle Scholar
  • 4 Dean BL, Flom RA, Wallace RC, et al. Efficacy of endovascular treatment of meningiomas: evaluation with matched samples. AJNR Am J Neuroradiol 1994; 15:1675-1680. MedlineGoogle Scholar
  • 5 Han MH, Seong SO, Kim HD, Chang KH, Yeon KM, Han MC. Craniofacial arteriovenous malformation: preoperative embolization with direct puncture and injection of n-butyl cyanoacrylate. Radiology 1999; 211:661-666. LinkGoogle Scholar
  • 6 Chan RC, Thompson GB. Morbidity, mortality, and quality of life following surgery for intracranial meningiomas: a retrospective study in 257 cases. J Neurosurg 1984; 60:52-60. Crossref, MedlineGoogle Scholar
  • 7 Yamasaki F, Yoshioka H, Hama S, Sugiyama K, Arita K, Kurisu K. Recurrence of meningiomas. Cancer 2000; 89:1102- 1110. Crossref, MedlineGoogle Scholar
  • 8 Nelson PK, Setton A, Choi IS, Ransohoff J, Berenstein A. Current status of interventional neuroradiology in the management of meningiomas. Neurosurg Clin N Am 1994; 5:235-259. Crossref, MedlineGoogle Scholar
  • 9 Gobin YP, Garcia-de-la-Fuente JA, Herbreteau D, Houdart E, Merland JJ. Endovascular treatment of external carotid-jugular fistulae in the parotid region. Neurosurgery 1993; 33:812-816. Crossref, MedlineGoogle Scholar
  • 10 Herbreteau D, Aymard A, Jhaveri HS, et al. Current management of cervicofacial superficial vascular malformations and hemangiomas. In: Connors JJ, Wojak JC, eds. Interventional neuroradiology. Philadelphia, Pa: Saunders, 1999; 317-327. Google Scholar
  • 11 Gobin YP, Laurent A, Merienne L, et al. Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 1996; 85:19-28. Crossref, MedlineGoogle Scholar
  • 12 Casasco A, Houdart E, Biondi A, et al. Major complications of percutaneous embolization of skull-base tumors. AJNR Am J Neuroradiol 1999; 20:179-181. MedlineGoogle Scholar
  • 13 Kerber CW, Wong W. Liquid acrylic adhesive agents in interventional neuroradiology. Neurosurg Clin N Am 2000; 11:85-99. Crossref, MedlineGoogle Scholar
  • 14 Taki W, Yonekawa Y, Iwata H, Uno A, Yamashita K, Amemiya I. A new liquid material for embolization of arteriovenous malformations. AJNR Am J Neuroradiol 1990; 11:163-168. MedlineGoogle Scholar
  • 15 Chaloupka JC, Huddle DC, Alderman J, Fink S, Hammond R, Vinters HV. A reexamination of the angiotoxicity of superselective injection of DMSO in the swine rete embolization model. AJNR Am J Neuroradiol 1999; 20:401-410. MedlineGoogle Scholar
  • 16 Lee DH, Wriedt CH, Kaufmann JC, Pelz DM, Fox AJ, Vinuela F. Evaluation of three embolic agents in pig rete. AJNR Am J Neuroradiol 1989; 10:773-776. MedlineGoogle Scholar
  • 17 Lylyk P, Vinuela F, Vinters H, et al. Use of a new mixture for embolization of intracranial vascular malformations. Neuroradiology 1990; 32:304-310. Crossref, MedlineGoogle Scholar
  • 18 Gobin YP, Vinuela F, Vinters H, Ji C, Chow K. Experimental study of a new embolic material: polyacrylonitrile hydrogel radio-opaque microbeads. Radiology 2000; 214:113-119. LinkGoogle Scholar
  • 19 Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y. Detachable balloon and calibrated-leak balloon techniques in the treatment of cerebral vascular lesions. J Neurosurg 1978; 49:635-649. Crossref, MedlineGoogle Scholar
  • 20 Ricolfi F, Gobin YP, Aymard A, Brunelle F, Gaston A, Merland JJ. Giant perimedullary arteriovenous fistulas of the spine: clinical and radiologic features and endovascular treatment. AJNR Am J Neuroradiol 1997; 18:677-687. MedlineGoogle Scholar
  • 21 Quinones D, Duckwiler G, Gobin PY, Goldberg RA, Vinuela F. Embolization of dural cavernous fistulas via superior ophthalmic vein approach. AJNR Am J Neuroradiol 1997; 18:921-928. MedlineGoogle Scholar
  • 22 Guglielmi G, Vinuela F, Dion J, Duckwiler G. Electrothrombosis of saccular aneurysms via endovascular approach. II. Preliminary clinical experience. J Neurosurg 1991; 75:8-14. Crossref, MedlineGoogle Scholar
  • 23 Sorimachi T, Koike T, Takeuchi S, et al. Embolization of cerebral arteriovenous malformations achieved with polyvinyl alcohol particles: angiographic reappearance and complications. AJNR Am J Neuroradiol 1999; 20:1323-1328. MedlineGoogle Scholar
  • 24 Nichols DA, Rufenacht DA, Jack CR, Forbes GS. Embolization of spinal dural arteriovenous fistula with polyvinyl alcohol particles: experience in 14 patients. AJNR Am J Neuroradiol 1992; 13:933- 940. MedlineGoogle Scholar
  • 25 Repa I, Moradian GP, Dehner LP, et al. Mortalities associated with use of a commercial suspension of polyvinyl alcohol. Radiology 1989; 170:395-399. LinkGoogle Scholar
  • 26 Dion JE. Principles and methodology. In: Vinuela F, Halbach VV, Dijon JE, eds. Interventional neuroradiology. New York, NY: Raven, 1992; 1-17. Google Scholar
  • 27 Rao VRK, Mandalam KR, Gupta AK, Kumar S, Joseph S. Dissolution of isobutyl 2-cyanoacrylate on long-term follow-up. AJNR Am J Neuroradiol 1987; 10:135- 141. Google Scholar
  • 28 Wikholm G. Occlusion of cerebral arteriovenous malformations embolized with n-butyl cyanoacrylate is permanent. AJNR Am J Neuroradiol 1995; 16:479-482. MedlineGoogle Scholar
  • 29 Debrun GM, Aletich V, Ausman JI, Charbel F, Dujovny M. Embolization of the nidus of brain arteriovenous malformations with n-butyl cyanoacrylate. Neurosurgery 1997; 40:112-121. Crossref, MedlineGoogle Scholar
  • 30 Chaloupka JC, Vinuela F, Vinters HV, Robert J. Technical feasibility and histopathologic studies of ethylene vinyl copolymer (EVAL) using a swine endovascular embolization model. AJNR Am J Neuroradiol 1994; 15:1107-1115. MedlineGoogle Scholar
  • 31 Murayama Y, Vinuela F, Zenteno M, et al. Non-adhesive liquid embolic agent for neuroendovascular applications: experimental studies and preliminary clinical utilization in brain arteriovenous malformations. Intervent Neuroradiol 1997; 3S:101. Google Scholar
  • 32 Vinters HV, Lundie MJ, Kaufmann JCE. Long term pathological follow-up of cerebral arteriovenous malformations treated by embolization with bucrylate. N Engl J Med 1986; 314:477-483. Crossref, MedlineGoogle Scholar
  • 33 Germano IM, Davis RL, Wilson CB, Hieshima GB. Histopathological follow-up study of 66 cerebral arteriovenous malformations after therapeutic embolization with polyvinyl alcohol. J Neurosurg 1992; 76:607-614. Crossref, MedlineGoogle Scholar
  • 34 Schweitzer JS, Chang BS, Madsen P, et al. The pathology of arteriovenous malformations of the brain treated by embolotherapy II. Results of embolization with multiple agents. Neuroradiology 1993; 35:468-474. Crossref, MedlineGoogle Scholar

Article History

Published in print: Nov 2001