Pre-surgical embolization of vertebral lesions Our experience

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1 Prof. Marco Leonardi Servizio e Cattedra di Neuroradiologia Università di Bologna Ospedale Bellaria Pre-surgical embolization of vertebral lesions Our experience Dr Luigi Simonetti Altin Stafa, Carlotta Barbara, Luigi Simonetti, Stefano Boriani, Marco Leonardi

2 Selective arterial embolization (SAE) of Hypervascularized Spinal Tumors Rationale -Vertebral localization: circa 70% of bone metastatic cancers (Prostate, breast, lung, kidney, thyroid gland) -Most of the vertebral tumors will cause neurological symptomatology. - Surgery is often mandatory. - According to current literature, average of en bloc surgical spondilectomy blood loss: 3,5-4,0 L - Pre-surgical Selective Arterial Embolization (SAE) to limit blood loss.

3 Selective arterial embolization (SAE) of Hypervascularized Spinal Tumors Our series of patients Review on 379 patients who underwent SAE, , in 2 Neuroradiological centers. 209M (55%), 170 F (45%); mean age 49.2 y, range 4-82 yo.

4 Selective arterial embolization (SAE) of Hypervascularized Spinal Tumors Our series 379 patients 453 sessions Circa 1210 pedicles (metameric arteries and other afferents) 13% 45% 35% 7% Benign (28%) Malignant (72%) 20 0 Cervical Thoracic Lumbar Sacral Site of lesions 379 patients Type of lesions in 379 patients

5 Schwannoma Osteoangioma Emangioendotelyoma Giant Cell Tumor Osteocondroma Osteoblastoma Aneurysmal bone cyst Benign lesions: hystologic type and site in 106/379 patients (28%) Cervical Osteoangioma Thoracic Osteoblastoma Lumbar Sacral Aneurysmatic bone cyst 24 Schwannoma 8 Giant cell Tumors 6 6 Hemangioendotelioma 5 4 Osteocondroma 1 2 Thoracic 48 0 Lumbar 27 Cervical 20 Sacral 11

6 Metastasis Chordoma Plasmocitoma Lymphoma Osteosarcoma Ewing Sarcoma Malignant lesions: hystological type and site in 273/379 patients (72%) 80 Cervical Thoracic Lumbar Sacral Metastasis 241 (89%) Osteosarcoma 19 Plasmocytoma 8 Ewing Sarcoma 3 Lymphoma 1 Chordoma 1 0 Thoracic 135 Lumbar 83 Cervical 43 Sacral 12

7 Embolic Materials in 1210 pedicles coil dissection balloon glubran particles Particles: 68% Glubran2 : 29% Coils: 2% Dissections: 0,5% Balloon: 0,5%

8 TECHNICAL ASPECTS Attention on ASA and Adamkiewitz artery Superselective angiography via microcath. Flow control Choice of embolic materials

9 TECHNICAL ASPECTS Attention on ASA & Adamkiewitz artery Superselective angiography via microcatheter Flow control Choice of Embolic Materials Attention on ASA + Adamkiewitz artery Anatomical Recall Adamkiewicz Artery (AKA) Magnus ramus radicularis anterior Great anterior radiculomedullary artery AKA is the largest anterior segmental medullary artery Origin level: -T9-T12 (70% of the cases) Left-side predominance (70%) -L1-L2 (15% of the cases) Diameter: 0,7-1,3m

10 TECHNICAL ASPECTS AKA & ASA High frequency of AKA origin Thoracic level (70%)

11 TECHNICAL ASPECTS AKA is the largest, but not the only anterior segmental medullary artery Important difference of procedural risk between: Spinal surgery Thoracic Vascular Surgery Superselective arterial embolization

12 Surgical Ligation of AKA

13 Surgical Ligation of AKA In many surgical experiences, ligation of AKA does not produce adverse clinical effects.

14 TECHNICAL ASPECTS 36 yo M CT scan guided biopsy: Chondrosarcoma According to the surgeon, AKA was legated with no important adverse clinical events T10 Courtesy of Dr Boriani IOR Rizzoli Bologna

15 TECHNICAL ASPECTS After T10 En bloc excision and T10 AKA ligation, a new AKA is born in T6

16 Vascular Aorta Surgery / Endoprosthesis Aneurism repair Ligation / closure of AKA and accessory segmental anterior medullary Medullar infarction

17 AKA accidental embolization

18 AKA accidental embolization

19 AKA accidental embolization

20 TECHNICAL ASPECTS The blured anterior segmental medullary artery

21 The blured anterior segmental medullary artery

22

23 TECHNICAL ASPECTS Attention on ASA Adamkiewitz artery Superselective angiography via microcatheter Flow control Choice of Embolic Materials Superselective microcatheterization - 4F diagnostic catheter (Cobra / Simons) and coaxial microcatheterization (Boston Renegade upon Transend) -High-resolution DS angiography and road-mapping are necessary. Superselective catheterization was successfully performed in: / 1210 pedicles treated (70% overall), - in all the SAE with glue (100% Glubran2), - in 641/986 pedicles (65%) using particles.

24 Superselective Microcath M/47 Right T11 Renal K metastasis

25 Superselective Microcath M/47 Right T11 Renal K metastasis Superselective catheterization and particles injection

26 Superselective Microcath M/16 L1 Osteoangioma Selective angiography, right metamerical

27 Superselective Microcath Superselective angiography and Glubran2 injection

28 TECHNICAL ASPECTS Attention on ASA Adamkiewitz artery Superselective angiography via microcatheter Flow control Choice of Embolic Materials Flow control When micro-catheterization is unstable or impossible: we inject particles from the guiding catheter, taking advantage of the preferential flow of the metameric artery (slow and carful injection to avoid back flow of particles). If anastomoses are present, the flow inversion of collateral circle toward the lesion is used to lead the particles into the lesion, (the origin of the metameric artery is taken occluded by pushing the guiding cath forward).

29 Flow control F/68 yo T11 Meta Breast K Particles injection From the guiding cath.

30 TECHNICAL ASPECTS Attention on ASA Adamkiewitz artery Superselective angiography via microcatheter Flow control Choice of embolic materials Choice of embolic materials PARTICLES (mainly Hydrophilic acrylic co-polymer -Embosphere; sometimes PVA- Contour) Good penetration within the lesion Easy to handle Available in different size ( microns) depending on the type of pathological circulation (generally we use μ, μ). We embolize allmost all vertebral metastasis with particles

31 BUT PARTICLES Sometimes make the embolization relatively unstable (particles could move following the flow, or can be absorbed). The smallest (50 μ) particles have the advantage of a good intralesional penetration, but they can drive to embolization of erroneous branches through invisible shunts (we don t use them!) Larger particles ( and μ) are safer, but they tend to agglutinate, causing a more proximal embolization. Particles penetration sometimes may even be excessive, transforming a highly vascularized tumor in a dry and fragile pulp (difficulty for the en bloc due to rupture during surgery)

32 TECHNICAL ASPECTS Attention on ASA Adamkiewitz artery Superselective angiography via microcatheter Flow control Choice of embolic materials Choice of embolic materials GLUBRAN2 Good lesion penetration (even into small comb-shaped vessels) it simulate the angiographic vascular image of the lesion vascularized circulation, helping the choice of the next part of circle to embolize; it avoids the excessively distal embolization.

33 F/12 yo C3 Aneurismatic bone cyst

34 F/12 yo C3 Aneurismatic bone cyst First step: balloon occlusion of the right vertebral artery

35 F/12 yo C3 Aneurismatic bone cyst Second step Superselective angiography Glubran2 injection

36 Right C3-C4 Neurinoma Glubran2

37 Tecnical/angiografical results of embolization in 379 patients Total embolization: Non significant angiograficaly evident residual pathological circulation Sub-total embolization: 10-30% of residual angiograficaly evident residual pathological circulation Partial embolization: >30% of residual angiograficaly evident residual pathological circulation

38 Technical results of embolization 379 patients Total (82%) 311 Sub-total (4%) Partial (6%) Failed (8%)

39 Causes of partial result Sub-total embolization in 15/379 patients (4%). - Too much feeders! (ex. Osteoblastoma) Partial embolization in 23/379 patients (6%): ASA orig. from one of the metameric arteries feeding the lesion (9 pts, 1 cerv. 1 lumb. 7 thor); Presence of potentially dangerous anastomoses (2 pts) Severe atherosclerotic changes (5 pts).

40 Results by a surgical point of view The blood loss estimated by surgeons during tumour resection was obtained from the surgical records. The mean reduction of blood loss after SAE was estimated to be at 50 to 80%.

41 Complications Complications occurred in 2/379 patients, 0,5%

42 Complications 1 Pt: 58 yo M, C4-C5 meta from renal K, left side Brown-Séquard Syndrome. - SAE using GDC coils in two large feeders arising from the left vertebral artery; neurological impairment 3 hours later. - MRI performed 12 h later was normal. The syndrome partially regressed in 48 h, after steroid therapy; the patient underwent surgery with a good clinical outcome. (Coil-originated embolism?) 2 Pt: 15 yo F, recurrent osteoblastoma T11, mild lower limb weakness 36 h after SAE. - SAE with particles in both metameric arteries. - MR examination showed an intramedullary small hyperintense lesion located at T8. (Delayed embolic medullary ischemia do to anastomosis?)

43 Focus on SAE of vertebral Aneurysmal Bone Cysts (ABC)

44 Aneurysmal Bone Cyst 24 patients 10 After Selective Arterial Embolization: A complete resolution or important decrease of pain was observed in all cases after 1 or 2 sessions. Cervical Thoracic Lumbar Sacral CT evidence of regression and/or recalcification of the cyst in 14 cases (follow-up 9-37 months)

45 F/12 yo Hard, drug-resistent cervico-brachial pain Right C5 ABC

46 F/12 yo 2 sessions, 2 pedicles (one of them: the vertebral artery) 1 step: Proximal and distal GDC occlusion of right Vertebral artery

47 F/12 yo 2 sessions, 2 pedicles (one of them: the vertebral artery) 2 step: Glubran2 injection, branches of deep cervical artery

48 F/12 yo 1 month CT control Fine calcifications into the cyst

49 F/12 yo 10 months CT follow-up

50 F/6 yo Persistent stiff neck, hard neck pain Left C4, ABC

51 1 session, 1 pedicle Glubran2 Injection

52 12 months CT follow-up xx xx xx xx xx xx xx xx xx

53 F/13 yo Hard cervico-brachial pain C7 right ABC

54 5 sessions, 10 pedicles

55 12 months CT follow-up

56 F/15 yo Right sciatica, enuresis Right sacral ABC

57 5 sessions: 3 SAE, 2 direct punctures, Glubran2

58 6 months follow-up

59 Conclusions about ABCs If confirmed in larger series, SAE seems to be the first treatment option for vertebral aneurysmal bone cyst (low costto-benefit ratio). Diagnosis must be certain (radiologic and/or histologic pattern). If neurologic progression or pathologic fractures occurs, in case of technical impossibility to perform SAE, or local recurrence after at least 3 embolization procedures, surgery remains the solution.

60 Conclusions about SAE of spine tumors Preoperative SAE of hypervascular spine tumours in our experience could be considered ad a safe and effective procedure. SAE can help surgery: it can help to make possible a complete resection of a tumour or can help to make resectable an otherwise unresectable tumour. Accurate diagnosis, superselective catheterization and flow control are required to ensure safe devascularization and to avoid complications.

61 Thank you!