Use of the Apollo detachable-tip microcatheter for endovascular embolization of arteriovenous malformations and arteriovenous fistulas

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OBJECTIVE

Liquid embolic agents have revolutionized endovascular management of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs). Nonetheless, since 2005, the US FDA has received more than 100 reports of microcatheter breakage or entrapment related to Onyx embolization, including 9 deaths. In 2014, the Apollo detachable-tip microcatheter became the first of its kind available in the US. Since then, few reports on its safety have been published.

METHODS

The authors conducted a retrospective review of endovascular cases by searching the patient databases at 2 tertiary cerebrovascular centers (Barrow Neurological Institute and University of Pittsburgh Medical Center). Patients who underwent endovascular embolization of an AVM or AVF using the Apollo microcatheter were identified. Patient demographics and lesion characteristics were collected. The authors analyzed Apollo-specific endovascular variables, such as number of microcatheterizations, sessions, and pedicles embolized; microcatheter tip detachment status; obliteration rate; and endovascular- and microcatheter-related morbidity and mortality.

RESULTS

From July 2014 to October 2016, a total of 177 embolizations using the Apollo microcatheter were performed in 61 patients (mean age 40.3 years). The most frequent presentation was hemorrhage (22/61, 36.1%). Most lesions were AVMs (51/61, 83.6%; mean diameter 30.6 mm). The mean Spetzler-Martin grade was 2.4. Thirty-nine (76.5%) of 51 patients with AVMs underwent resection. Microcatheterization was successful in 172 pedicles. Most patients (50/61, 82%) underwent a single embolization session. The mean number of pedicles per session was 2.5 (range 1–7). Onyx-18 was used in 103 (59.9%), N-butyl cyanoacrylate (NBCA) in 44 (25.6%), and Onyx-34 in 25 (14.5%) of the 172 embolizations. In 45.9% (28/61) of the patients, lesion obliteration of 75% or greater was achieved. Tip detachment occurred in 19.2% (33/172) of microcatheters. Fifty-three (86.9%) of the 61 patients who underwent embolization with the Apollo microcatheter had good functional outcomes (modified Rankin Scale score 0–2). No unintended microcatheter fractures or related morbidity was observed. One patient died of intraprocedural complications unrelated to microcatheter selection. In the univariate analysis, microcatheter tip detachment (p = 0.12), single embolized pedicles (p = 0.12), and smaller AVM nidus diameter (p = 0.17) correlated positively with high obliteration rates (> 90%). In the multivariate analysis, microcatheter tip detachment was the only independent variable associated with high obliteration rates (OR 9.5; p = 0.03).

CONCLUSIONS

The use of the Apollo detachable-tip microcatheter for embolization of AVMs and AVFs is associated with high rates of successful catheterization and obliteration and low rates of morbidity and mortality. The microcatheter was retrieved in all cases, even after prolonged injections in distal branch pedicles, often with significant reflux. This study represents the largest case series on the application of the Apollo microcatheter for neurointerventional procedures.

ABBREVIATIONS AVF = arteriovenous fistula; AVM = arteriovenous malformation; DMSO = dimethyl sulfoxide; EVOH = ethylene vinyl alcohol; NBCA = N-butyl cyanoacrylate.

Article Information

Correspondence Felipe C. Albuquerque: c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. neuropub@barrowneuro.org.

INCLUDE WHEN CITING Published online March 23, 2018; DOI: 10.3171/2017.9.JNS17397.

Disclosures Dr. Ducruet: consultant for Medtronic.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Left: Intact Apollo microcatheter with 2 distinct components: the primary catheter and the detachable tip. The orange segment contains a radiopaque proximal marker within it, and the gray detachable segment contains a second distal radiopaque marker at the tip. The separation point is approximately midway along the orange segment and is immediately distal to the radiopaque marker. Right: Apollo microcatheter showing a detached tip. Figure is available in color online only.

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    A: Anteroposterior (AP) right internal carotid artery (ICA) subtracted angiogram of a Spetzler-Martin grade IV unruptured AVM in the right frontal region in a patient who presented with seizures refractory to medical therapy. This image demonstrates an arterial supply from the right pericallosal artery, the right callosomarginal artery, the right parietal cortical middle cerebral artery branches, and a lateral lenticulostriate artery. B: A large Onyx embolysate cast is visible in this AP native fluoroscopic image. An occipital neuromonitoring lead is visible at the medial aspect of the Onyx cast, and an Apollo microcatheter is visible in the inferomedial corner within an intermediate catheter (note the 2 radiopaque markers defining the Apollo detachment zone and the Apollo distal tip). A previously detached Apollo tip is visible on the inferior aspect of the Onyx cast (arrows). C: Final postembolization AP right ICA subtracted angiogram demonstrating 60% angiographic obliteration. This patient underwent 4 endovascular sessions, with 14 embolized pedicles (13 using Apollo microcatheters); NBCA, Onyx-18, and Onyx-34 were used as liquid embolysates. D: Postoperative follow-up AP right ICA subtracted angiogram demonstrating complete resection.

  • View in gallery

    Left: A Spetzler-Martin grade II AVM in the right cerebellar hemisphere in a patient who presented with hemorrhage. The arterial supply to the AVM was primarily through the right anterior inferior cerebellar artery and the right superior cerebellar artery. The AVM was preoperatively embolized using an Apollo microcatheter and Onyx-18 through a single pedicle off the right anterior inferior cerebellar artery. Right: Postembolization oblique subtracted angiogram revealing complete angiographic obliteration. Note the subtracted image of the detached microcatheter distal tip (arrow).

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