Preoperative Onyx Embolization of Vascular Head and Neck Tumors by Direct Puncture

ObjectivePreoperative embolization of hypervascular head and neck tumors is frequently performed to reduce operative times and blood loss. While traditional transarterial embolization is commonly used, direct tumoral puncture has also been advocated as an alternative. We report our series of head and neck tumors embolized with Onyx via direct tumoral puncture to ascertain the safety and efficacy of embolization using this technique.MethodsWe prospectively collected data on all head and neck tumors embolized with Onyx at our institution during a 24-month period.ResultsA total of 18 patients underwent preoperative embolization via direct tumoral puncture. Tumors included nine carotid body tumors, three glomus vagale tumors, five juvenile nasopharyngeal angiofibromas (JNAs), and one intracranial frontal parasagittal meningioma. All embolizations were completed in a single session. Mean fluoroscopy time was 40 minutes. The overall mean percent tumor devascularization was 87%. Inadvertent transtumoral migration of Onyx into the superior sagittal sinus occurred during intraoperative embolization of the meningioma using single-plane fluoroscopy and resulted in a large postoperative hemorrhagic venous infarct. There were no other endovascular-related complications in the remaining patients embolized using biplanar fluoroscopy.ConclusionEmbolization of hypervascular head and neck tumors with Onyx via direct tumoral puncture can be performed safely and efficiently. Tumor embolization by direct puncture may theoretically lower the risk of inadvertent migration of Onyx through nontarget arterial vessels, but may increase the risk of inadvertent transtumoral embolization of venous structures. Caution should be exercised when using this technique for intracranial pathologies, and the importance of biplanar fluoroscopy to allow better visualization of the Onyx migration cannot be overemphasized.