Modified Pressure Cooker Technique: An Effective Way to Control Ethylene Vinyl Alcohol Copolymer Reflux in Peripheral Arteriovenous Malformations

Abstract

Background: Embolization of high flow pAVMs is a technical challenge. ethylene vinyl alcohol (EVOH) copolymer is a safe and effective liquid embolic agent routinely used in intracranial AVMs and its use is recently reported in peripheral AVMs as well. Most important technical challenge during ethylene vinyl alcohol (EVOH) copolymer injection is control of reflux. Modified Pressure Cooker Technique (mPCT) is a medthod to prevent reflux of EVOH which is well described in intracranial AVMs, however not reported in peripheral AVms. In Modified Pressure Cooker Technique a glus plug is created proximal to the devilary tip of detachable microcatheter in a unique way. We describe successful use of modified Pressure Cooker Technique (mPCT) in peripheral AVMs to control reflux and achieve adequate embolization. Method(s): Three patients with high flow peripheral AVMs were treated with ethylene vinyl alcohol (EVOH) copolymer (MENOX 18) embolization using modified Pressure Cooker Technique. We used Ultrasound guided Femoral access in all 3 cases. We used coaxial sytem using 7F 70 cm long Guiding sheath and intermediate catheter DAC 070. We used Combination of EVOH compatible detachable microcatheter (APOLLO 3 cm tip) and a non detachable microcatheter (Echelon 10) for nBCA glue plug creation needed for mPCT. We injected EVOH copolymer (Menox 18) via detachable APOLLO micro catheter and NBCA injection via the proximal catheter to create a glue plug to prevent EVOH copolymer reflux during injection of EVOH copolymer. Result(s): We achieved 100% Technical success: ethylene vinyl alcohol (EVOH) copolymer did not refluxed proximal to the glued segment of the detachable microcatheter and we had safe removal of detachable microcatheter post embolisation. Satisfactory embolization of the target nidus in all. No intra-operative complications. Conclusion(s): Use of modified Pressure Cooker Technique (mPCT)in peripheral AVMs is: (1) Safe and effective for ethylene vinyl alcohol (EVOH) copolymer injection. (2)Prevents reflux and allows forward progression of ethylene vinyl alcohol (EVOH) copolymer into nidus. (3) Can be applied in peripheral AVMs whenever ethylene vinyl alcohol (EVOH) copolymer is used as the embolic agent. Publication Date: 11 May 2021 (online) © 2019. The Arab Journal of Interventional Radiology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/). Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India