Percutaneous Embolization of Carotid Body Tumors to Aid Resection: Technical Note

Preoperative percutaneous embolization can be performed in patients with carotid body tumors to minimize blood loss and aid in resection of these highly vascularized lesions. Carotid body tumors are rare and often involve critical structure of the neck including cranial nerves. Surgical excision is necessary for these lesions and optimal surgical technique is required to maintain the delicate neighboring neurovascular structures. Traditionally, embolization has been achieved via a transarterial route via the femoral artery; however, embolization can also be successfully and safely achieved via direct percutaneous embolization. Percutaneous embolization allows for intralesional delivery of embolic particles and can be performed quicker than transarterial embolization. The procedure itself is not only low-risk, but also reduces the intraoperative risks associated with subsequent tumor resection. Prior studies have shown significant blood loss associated with carotid body tumor resection. Percutaneous embolization may reduce the risk of cerebral ischemia by reducing the risk of severe blood loss from the mass; moreover, Here, we present two patients with carotid body tumors that were preoperatively embolized via direct percutaneous embolization with ethylene vinyl alcohol copolymer (Onyx, [EV3, Irvine, CA, USA]).

Prior to embolization, a balloon occlusion test is performed in case there is need for carotid take down during the case. Patient undergoes general anesthesia, is kept in the supine position with the head rotated 30 degrees toward the contralateral shoulder, and antibiotics are administered. Using digital subtraction angiography, the angioarchitecture of the carotid tumor is identified ([Fig. 1]).

Next, a 21-gauge needle is inserted in a safe distance within the lesion itself and confirmed with intralesional angiography ([Fig. 2]).

Slow, continuous backflow of blood through the needle confirms appropriate location. Afterward, Onyx-18 is injected under road mask fluoroscopy after standard preparation with dimethyl sulfoxide (DMSO). With tactile feedback, the intratumoral injection can be felt to have decreased penetration and repeat angiography can be performed to evaluate further treatment. If necessary, the spinal needle trajectory can be repositioned for further treatment. A post-procedure CT is performed ([Fig. 3]).

There were no immediate post-procedural complications following embolization. All patients underwent definitive resection within 24 hours. During surgery, the embolization material did not affect surgical maneuvers. In addition, the estimated blood loss was noted to average 50 ml. There were no intraoperative or immediate postoperative complications and all patients were discharged home with no neurologic complications.

Preoperative embolization of carotid body tumors minimizes intraoperative blood loss and facilitates tumor resection. This procedure is a direct and safe method to reduce blood supply to otherwise highly vascularized tumors. The percutaneous route allows for a simplified, intralesional approach to embolization as opposed to transarterial embolization. Further investigations with larger study populations are necessary to demonstrate the risks and benefits of percutaneous embolization and should stratify patients based on bleeding risk, tumor size, and tumor type.

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Artikel online veröffentlicht:
01. Februar 2023