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Original research
Visibility of liquid embolic agents in fluoroscopy: a systematic in vitro study
  1. Niclas Schmitt1,
  2. Lena Wucherpfennig2,
  3. Sophia Hohenstatt1,
  4. Charlotte S Weyland1,
  5. Christof M Sommer3,4,
  6. Martin Bendszus1,
  7. Markus A Möhlenbruch1,
  8. Dominik F Vollherbst1
  1. 1Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
  2. 2Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
  3. 3Clinic of Radiology, University Hospital Heidelberg, Heidelberg, Germany
  4. 4Clinic of Radiology and Neuroradiology, Sana Kliniken Duisburg GmbH, Duisburg, Germany
  1. Correspondence to Dr Dominik F Vollherbst, Department of Neuroradiology, University Hospital Heidelberg, 69120 Heidelberg, Germany; dominik.vollherbst{at}med.uni-heidelberg.de

Abstract

Background Endovascular embolization using liquid embolic agents (LEAs) is frequently applied for the treatment of intracranial vascular malformations. Appropriate visibility of LEAs during embolization is essential for visual control and to prevent complications. Since LEAs contain different radiopaque components of varying concentrations, our aim was the systematic assessment of the visibility of the most used LEAs in fluoroscopy.

Methods A specifically designed in vitro model, resembling cerebral vessels, was embolized with Onyx 18, Squid 18, Squid 12, PHIL (precipitating hydrophobic injectable liquid) 25%, PHIL LV (low viscosity) and NBCA (n-butyl cyanoacrylate) mixed with iodized oil (n=3 for each LEA), as well as with contrast medium and saline, both serving as a reference. Fluoroscopic image acquisition was performed in accordance with clinical routine settings. Visibility was graded quantitatively (contrast to noise ratio, CNR) and qualitatively (five-point scale).

Results Overall, all LEAs provided at least acceptable visibility in this in vitro model. Onyx and Squid as well as NBCA mixed with iodized oil were best visible at a comparable level and superior to the formulations of PHIL, which did not differ in quantitative and qualitative analyses (eg, Onyx 18 vs PHIL 25% along the 2.0 mm sector: mean CNR±SD: 3.02±0.42 vs 1.92±0.35; mean score±SD: 5.00±0.00 vs 3.75±0.45; p≤0.001, respectively).

Conclusion In this systematic in vitro study, relevant differences in the fluoroscopic visibility of LEAs in neurointerventional embolization procedures were demonstrated, while all investigated LEAs provided acceptable visibility in our in vitro model.

  • Angiography
  • Arteriovenous Malformation
  • Fistula
  • Liquid Embolic Material
  • Vascular Malformation

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All relevant data generated or analyzed during this study are included in this published article (and its supplementary information files).

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All relevant data generated or analyzed during this study are included in this published article (and its supplementary information files).

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Footnotes

  • Contributors NS, MB, MAM and DFV initiated the project. NS and DFV led the research, conducted the data acquisition, statistical analysis and wrote the manuscript. MB, MAM and DFV were involved in the study design and concept. DFV is the guarantor of this work. LW, SH, CSW and CMS participated in data acquisition. All authors discussed the results, commented on the paper, and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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