Embolization Materials

INDICATIONS
1. Occlusion of vascular abnormalities which have potential to cause adverse health effects
2. Acute or recurrent hemorrhage.
3. Devascularization of benign or malignant tumors for palliation or to reduce operative blood
loss.
4. Ablation of non-neoplastic tissue causing adverse health effects
5. Flow redistribution to protect normal tissue or to facilitate subsequent treatment
6. Endoleak management.
7. Vehicle for targeted delivery of drugs or other agents
MECHANICAL OCCLUSIVE
DEVICES
COIL
•Coils are made from either stainless steel or platinum and are available in a wide variety of sizes.
•They may have Dacron fibers placed at right angles to the long axis of the coil, or coatings such
as hydrogel, to increase the surface area and thereby increase the speed and permanence of
thrombosis
•Coils rely on mechanical obstruction, platelet activation, and the patient’s own clotting cascade
to fully occlude vessels.
•As a result, in the presence of thrombocytopenia and coagulopathy, the efficacy of embolization
is compromised
 MECHANICAL OCCLUSIVE
DEVICES
COIL
Coil stability is essential to prevent nontarget embolization. Achieving stability can be aided by the following:
1. The use of a guiding catheter
2. A certain degree of oversizing is essential to minimize the risk of dislodgement
3. Detachable coil designs allow testing of stability before detaching the coil and may be preferred in high-
risk situations.
a. In a high-flow arteriovenous malformation (AVM) or arteriovenous fistula, embolization can be performed using
detachable coils and the double microcatheter technique

4. Coil anchoring devices: are particularly useful forocclusion of large arteriovenous fistulae in the lungs,
and large portosystemic collaterals
a. The Amplatz Spider (Cook, Inc., Bloomington, IN) is a stainless-steel self- expanding metallic device that can be
introduced through a guiding catheter or vascular sheath.
b. Retrievable coil anchors offer the advantage of improved safety due to the ability to retrieve and redeploy
suboptimally placed devices
MECHANICAL OCCLUSIVE
DEVICES
Vascular Plugs
•Vascular plugs are permanent occlusive devices using nitinol mesh in a 3D disc geometry.
•Plugs should be oversized relative to the target vessel diameter by 30% to 50% as recommended
by the manufacturer.
•The devices are deployed by unscrewing the lock in a counterclockwise direction, therefore
precise positioning and repositioning can be performed.
•In general, due to their compact design, the relatively large surface area, and tight nitinol mesh
structure, plugs should be considered when single-step occlusion of a larger vessel or branch is
desired, or when an initial plug is needed to act as a scaffold for later adjunct embolization
•Plugs can be used to occlude internal iliac arteries prior to the deployment of aortoiliac stent
grafts, exclusion of visceral arterial aneurysms, ascending aortic pseudoaneurysms, or
emergency embolization of active bleeding.
MECHANICAL OCCLUSIVE
DEVICES
Balloons
•Detachable balloons were on the market in the United States several years ago but were
recalled due to both manufacturing problems and the difficulties in accurately placing the
balloons.
•The use of these devices has been replaced by detachable coils that allow exchange for another
size if the first deployment is incorrect
PARTICULATE EMBOLIC
AGENTS
Gelfoam
•Gelfoam (Upjohn Company, Kalamazoo, MI) is a water-insoluble haemostatic agent prepared
from purified skin gelatin.
•It was the first embolic particle used in humans.
• Gelfoam induces hemostasis by hastening development and providing structural support to the
thrombus.
•The use of Gelfoam is mainly linked to its temporary effect; it is used mainly to either stop
bleeding or to devascularize a lesion prior to surgical removal.
•Gelfoam is usually resorbed completely with little tissue reaction.
•When used as an embolic material, the vessel recanalizes within a few weeks
PARTICULATE EMBOLIC
AGENTS
Avitene
•Avitene (Davol, Inc., Cranston, RI) is a microfibrillar collagen preparation supplied in the form of
a powder.
•Moderate recanalization occurs by 2 weeks and total recanalization by 2 months.
•It is a useful agent for tumor necrosis and organ ablation as it can be delivered through a
microcatheter.
PARTICULATE EMBOLIC
AGENTS
Polyvinyl Alcohol
• The original PVA embolic particles (Cook, Bloomington, IN; Boston Scientific, Natick, MA) are still in use
• They are irregularly shaped shavings from blocks or sheets and are available in sizes from 50 to 1200
m. PVA is also supplied in the form of microspheres (Contour SE, Boston Scientific, Natick, MA)
• PVA particles produce mechanical occlusion of the vessel in addition to activation of thrombin and
inducing fibroblast ingrowth, which leads to a relatively permanent occlusion.
• Proposed mechanisms for recanalization include angioneogenesis and capillary regrowth caused by
vascular proliferation inside the organized thrombus, and resorption of the thrombus found among
clumps of PVA in the lumen of an embolized vessel after the resolution of inflammation.
• PVA particles are distributed dry or in solution. To be used, they have to be mixed in a solution of
contrast and saline.
• PVA particles tend to clump, leading to occlusion of vessels that are larger than the diameter of the
individual particles.
PARTICULATE EMBOLIC
AGENTS
Spherical Embolics (“Microspheres”)
• The principal advantages of spherical embolic agents are ease of injection and less clogging of catheters,
resulting in more predictable levels of occlusion.
• Several spherical embolic agents have been developed
• The first to be used in patients, Embosphere microspheres (BioSphere Medical, Rockland, MA), are
biocompatible, hydrophilic, nonresorbable, precisely calibrated trisacryl gelatin particles.
• Embospheres have FDA approval for use in hypervascular tumors and uterine fibroid embolization.
• Microspheres are available in sizes of 40 to 1200 μm and are supplied in apyrogenic sterile sodium
chloride solution.
• There are physical and mechanical differences between each of the spherical embolic agents that can
significantly influence clinical outcomes.
• For any given embolization procedure, each type of microsphere differs in the size of particles used and
angiographic end point.
 PARTICULATE EMBOLIC
AGENTS
Drug-Eluting Particles
• Drug-eluting microspheres offer the possibility of simultaneous embolization with sustained controlled drug
release.
• The beads have been most commonly loaded with chemotherapeutic agents although in theory any water-
soluble biologically active agent could be delivered by microsphere.
• Currently two types of drugeluting beads are available:
• 1. Unloaded beads which the physician loads by soaking in his or her medication of choice. These include
• a. DC Bead nonbiodegradable PVA microspheres (Biocompatibles, Farnham, UK): Most reports of this agent have been on the use of doxorubicin-
loaded beads for the treatment of hepatocellular carcinoma.
• b. QuadraSphere microspheres (BioSphere Medical): These superabsorbent polymer (SAP) microspheres are biocompatible, hydrophilic,
nonresorbable, acrylic copolymer microspheres that can absorb up to 64 times their dry-state volume. SAP microspheres can be loaded with
doxorubicin or cisplatin and to date have been largely used for the embolization of hepatoma.
• 2. Preloaded microspheres (Precision Bead Biocompatibles) is a PVA polymer hydrogel preloaded with 37.5-mg
doxorubicin per vial.

• The theoretical advantages of drug-loaded particles include a higher local concentration of the therapeutic
agent, longer exposure of the target to the therapeutic agent, and the potential to use drugs that are
potentially toxic if injected systemically.
 LIQUID EMBOLIC AGENTS
Glue
• Glue (cyanoacrylate) is a fast and efficient nonresorbable, nonradiopaque embolic material
• Liquid monomeric cyanoacrylate is converted to a solid long-chain polymer immediately on contact with anionic substances such as
plasma, blood cells, endothelium, or saline.
• The reaction proceeds so rapidly that the glue will solidify in a catheter unless a substance is added that extends the polymerization time.
• The most commonly used agent is ethiodized oil (Ethiodol, Lipiodol), typically in cyanoacrylate to oil ratios ranging from 1:5 to 2:5
depending on length of time needed until polymerization.
• Some operators also add powdered tantalum to increase radiopacity during injection, particularly for intracranial procedures.
• Histopathologic studies of glue demonstrate that cyanoacrylate provokes a more intense inflammatory reaction than that caused by PVA
and involves the wall of the vessel and the adjacent interstitial areas. This inflammatory reaction ultimately leads to vessel necrosis,
fibrous ingrowth, and permanent occlusion.
• The most common applications of glue are the treatment of vascular malformations, particularly intracranial, although it has been applied
throughout the body for virtually every embolic indication.
• Risks of using cyanoacrylates include rapid polymerization and reflux resulting in gluing the catheter in place or feeding vessel occlusion
without nidal penetration
• If the polymerization time is too long, the cyanoacrylate can pass into the venous circulation, resulting in pulmonary emboli.
 LIQUID EMBOLIC AGENTS
Onyx
• Onyx (ev3 Inc., Plymouth, MN) is a biocompatible liquid embolic agent.
• It is an ethylene vinyl alcohol copolymer dissolved in various concentrationsof dimethyl sulfoxide (DMSO) and opacified
with micronized tantalum powder.
• When this mixture contacts aqueous media such as blood,the DMSO rapidly diffuses away, resulting in in situ
precipitation and solidification of the polymer.
• It forms a soft elastic embolus without adhesion to the vascular wall or the catheter.
• The polymerization process is mainly influenced by the amount of ethylene vinyl acetate copolymer (EVOH) in the
mixture.
• The lower the concentration of EVOH, the less viscous the solution will be and the longer it will take to precipitate.
• Because the polymer will solidify on contact with aqueous media, the delivery catheter must be preflushed with DMSO.
• Onyx is nonadhesive, allowing for easy removal of the delivery catheter and of the polymer itself
• It is mainly used for intracranial aneurysms, however, in peripheral embolization Onyx has been successfully used for the
treatment of conditions such as endoleak and AVMs
LIQUID EMBOLIC AGENTS
Alcohol
•It can be injected via an intravascular route or direct percutaneous puncture
•Upon contact with the vessel wall, ethanol denudes the endothelium, which leads to thrombosis
and eventual fibrosis. On contact with blood, ethanol induces further thrombosis
•Permanent vascular occlusion
•This effective occlusion can be used to advantage for tumor or organ ablation, particularly renal
embolization, and by very skilled practitioners for the treatment of vascular malformations
The principal disadvantage of absolute ethanol is the risk of necrosis of neighboring tissues
(including nerves) or skin
The risk of systemic toxicity increases with doses above 1 mL/kg or if the total volume exceeds
60 mL
LIQUID EMBOLIC AGENTS
Ethanolamine Oleate
•Ethanolamine oleate (Ethamolin 5%; QOL Medical, Kirkland, WA) is a mixture of 5%
ethanolamine oleate (a synthetic mixture of ethanolamine and oleic acid) and ethiodol (ratio 5:1
to 5:2)
•It has excellent thrombosing properties combined with an inflammatory response in the
vascular wall to the oleic acid, provoking mural necrosis, thrombosis, and fibrosis.
•In comparison with ethanol, ethanolamine has a lesser penetrative effect, so it may be safer to
use in situations where vascular structures are in proximity to nerves
•Ethanolamine has been used predominantly for venous sclerosis, including gastroesophageal
varices and venous malformations, as well as for cyst sclerosis.
•Approximately 50% of the oleic acid may combine with serum proteins within 30 minutes and
can cause renal toxicity in association with a marked intravascular hemolysis, hemoglobinuria,
and hepatotoxicity
LIQUID EMBOLIC AGENTS
Sclerosants
• Sodium tetradecyl sulfate (Sotradecol, AngioDynamics, Queensbury, NY; Thromboject, Omega,
Montreal, Canada)
• is an anionic surfactant widely used for sclerosis of esophageal varices and varicose veins.
• It is a detergent containing 2% benzyl alcohol causing permanent vascular occlusion by erythrocyte sludging
and adventitial thrombosis.
• It is not as effective as other agents in the treatment of high-flow vascular malformations but can be used in
low-flow lesions.
• Although toxicities such as urticaria, anaphylaxis, hemolysis, and hematuria can be seen with larger doses, it is
generally a very safe, easy to use agent with low morbidity.

• Polidocanol (Aethoxysklerol, Kreussler, Wiesbaden, Germany)

• is a nonionic surfactant sclerosant that was first developed as an anesthetic.
• It causes vascular injury through endothelial overhydration.
• The agent’s attractive anesthetic properties make it nearly painless.
• Its use is primarily restricted to venous disease
LIQUID EMBOLIC AGENTS
Sclerosants
•Sodium morrhuate (Scleromate 5%, Glenwood LLC, Englewood, NJ)
• Is an irritant and sclerosing agent composed of a sodium salt of fatty acids in cod liver oil.
• This agent has been used in the treatment of varicose veins and venous malformations;
• It has been reported to be 1.5 to 4 times less effective than sodium tetradecyl sulfate

•Ethibloc (Ethicon, Norderstedt, Germany)

• Consists of a solution of zein, sodium amidotrizoate, oleum papaveris, and propylene glycol.
• It is derived from corn gluten and forms hard shells used in coatings of foods and pharmaceutical
products.
• Ethibloc has been used effectively for the treatment of venous, lymphatic and arteriovenous
malformations.
• It requires approximately 10 to 15 minutes to solidify into a viscous solution, allowing it to remain static
within the target lesion to cause intravascular thrombosis, necrosis, and fibrosis
 References
1.1. Golzarian J, Sun S, Sharafuddin MJ. Vascular Embolotherapy: A Comprehensive Approach, Vol. 1. Heidelberg: Springer; 2006.
2.Brown DB, Cardella JF, Sacks D, et al. Quality improvement guidelines for transhepatic arterial chemoembolization, embolization, and chemotherapeutic infusion for hepatic malignancy. J Vasc Interv Radiol.
2009;20:S219–S226.
3.Krysl J, Kumpe DA. Embolization agents: a review. Tech Vasc Interv Radiol. 2000;3:158–161.
4.Nambiar AP, Bozlar U, Angle JF, et al. Initial clinical experience with biopolymer-coated detachable coils (HydroCoil) in peripheral embolization procedures. J Vasc Interv Radiol. 2008;19(7):995–1001.
5.Greben CR, Setton A, Autterman D, et al. Double microcatheter single vascular access embolization technique for complex peripheral vascular pathology. Vasc Endovasc Surg. 2010;44:217–222.
6.White RI. Pulmonary arteriovenous malformations: how do I embolize? Tech Vasc Interv Radiol. 2007;10:283–290.
7.Wilson MW, Gordon RL, LaBerge JM. Intravascular occluding device using a modified gianturco stent as a coil cage. J Vasc Interv Radiol. 2000;11:221–224.
8.Kónya A, Wright KC. New retrievable coil anchors: preliminary in vivo experiences in swine. Cardiovasc Intervent Radiol. 2005;28(2):228–241
9.Lagana D, Carrafiello G, Mangini M, et al. Indications for the use of the Amplatzer vascular plug in interventional radiology. Radiol Med. 2008;113(5):707–718.
10.Mangini M, Lagana D, Fontana F, et al. Use of Amplatzer Vascular Plug (AVP) in emergency embolisation: preliminary experience and review of literature. Emerg Radiol. 2008;15(3): 153–160.
11.Scholtz W, Jategaonkar S, Haas NA. Successful interventional treatment of a retrosternal pseudoaneurysm of the ascending aorta with an Amplatzer Vascular Plug II. J Invasive Cardiol. 22(3):E44–E46.
12.Laurent A. Microspheres and nonspherical particles for embolization. Tech Vasc Interv Radiol. 2007;10(4):248–256.
13.Abada HT, Golzarian J. Gelatine sponge particles: handling characteristics for endovascular use. Tech Vasc Interv Radiol. 2007;10(4):257–260.
14.Liu DM, Salem R, Bui JT, et al. Angiographic considerations in patients undergoing liverdirected therapy. J Vasc Interv Radiol. 2005;16:911–935.
15.Lee KH, Liapi E, Ventura VP, et al. Evaluation of different calibrated spherical polyvinyl alcohol microspheres in transcatheter arterial chemoembolization: VX2 tumor model in rabbit liver. J Vasc Interv Radiol.
2008;19:1065–1069.
16.Varela M, Real MI, Burrel M, et al. Chemoembolization of hepatocellular carcinoma with drug eluting beads: efficacy and doxorubicin pharmacokinetics. J Hepatology. 2007;46:474–481.
17.Liapi E, Geschwind JF. Intra-arterial therapies for hepatocellular carcinoma: where do we stand? Ann Surg Oncol. 2010;17:1234–1246.
18.Golzarian J, Maes EB, Sun S. Endoleak: treatment options. Tech Vasc Interv Radiol. 2005;8: 41–49.
19.Howington JU, Kerber CW, Hopkins LN. Liquid embolic agents in the treatment of intracranial arteriovenous malformations. Neurosurg Clin N Am. 2005;16:355–363.
20.Ginat DT, Saad WE, Turba UC. Transcatheter renal artery embolization: clinical applications and techniques. Tech Vasc Interv Radiol. 2009;12:224–239.
21.Do YS, Yakes WF, Shin SW, et al. Ethanol embolization of arteriovenous malformations: interim results. Radiology. 2005;235:674–682.
22.Kaji N, Kurita M, Ozaki M, et al. Experience of sclerotherapy and embolosclerotherapy using ethanolamine oleate for vascular malformations of the head and neck. Scand J Plast Reconstr Surg Hand Surg.
2009;43:126–136.
23.Loffroy R, Guiu B, Cercueil JP, et al. Endovascular therapeutic embolisation: an overview of occluding agents and their effects on embolised tissue. Curr Vasc Pharmacol. 2009;7:250–263.
24.Woods JE. Extended use of sodium tetradecyl sulfate in treatment of hemangiomas and other related conditions. Plast Reconstr Surg. 1987;79:542–549.
Terimakasih