Adjunctive Techniques for large carotid body tumors percutaneous embolization, TCD monitoring
Odeaa Al Jabbari, Walid Abu Saleh, Orlando Diaz, Alan Lumsden
Houston Methodist Hospital, Houston, TX
Carotid body tumors are amongst the most vascular tumors encountered. Many surgeons opt for trans-arterial embolization using glue, onyx, or PVA particles for large tumors. Generally the tumoral blood supply arises from the external carotid branches. However, this circulation is very variable and non target organ embolization, especially the brain is a major concern.
In the case described the principle feeding vessels derived from both the external carotid branches and from a very large ipsilateral vertebral artery. Adequate embolization would have required challenging vertebral and tumor circulation catheterization, with risk of brain stem infarct. The objective was to minimize here risk of cerebral embolization using percutaneous embolization and TCD monitoring.
Direct tumor puncture has been described although rarely performed. We opted to perform direct transcutaneous tumor puncture in this challenging case. Principles include;
a) identify and avoid the main carotid arteries using advanced imaging techniques
b) define collateral pathways
c) establish baseline cerebral and brain stem circulation
d) ensure intravascular injection of Onyx
e) follow Onyx injection using the roadmap function
f) ensure both superficial and deep components of the tumor are addressed
g) understand technique for Onyx delivery
h) monitoring for embolization with TCD
Excellent angiographic devascularization was achieved by direct tumor injection. Perhaps surprisingly, surgical plans were not obscured and despite an extensive procedure, bleeding was very satisfactory.
This is a technique which can be mastered by vascular surgeons and represents an important additional tool when traditional routes of embolization are considered contraindicated.
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