J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.40.10.937 on 1 October 1977. Downloaded from Journal ofNeurology, Neurosurgery, andPsychiatry, 1977, 40, 937-950 Therapeutic embolisation of the external carotid arterial tree BRIAN KENDALL AND IVAN MOSELEY1 From the Lysholm Radiological Department, National Hospital for Nervous Diseases, Queen Square, London SUMMARY Intra-arterial embolisation is a valuable adjunct to the treatment of many vascular lesions, including neoplasms such as glomus tumours or juvenile angiofibromas, and arterio- venous malformations. Its place in the management of the individual patient should be established before any surgical procedure is carried out, as this may prejudice the eventual result. The indications for the procedure, the technique, and possible complications are discussed in this paper, and it is emphasised that the latter are best avoided by the use of a scrupulous technique and adequate technical facilities. guest. Protected by copyright. Therapeutic intra-arterial embolisation of vascular can, of course, be treated in other parts of the lesions is not a new technique; it was suggested in body. 1930 by Brooks, at a time when carotid angio- The contraindications to embolisation include graphy itself had been practised for only three allergy to angiographic contrast medium (but see years. Since then it has been used extensively as case 6), and atheroma of the carotid bifurcation, an adjunct to surgery or as definitive therapy, and which precludes selective catheterisation. There is the purpose of the present article is to describe little indication for the treatment of lesions which some of its applications and advantages in the present no difficulty at surgery and are unlikely to management of vascular lesions of the neck and produce poor cosmetic results. head. Brooks (1930) recommended muscle as the The aim of intravascular embolisation is to embolic material, while later workers have used occlude the blood vessels of a tumour or other radio-opaque metallic, plastic, or silicone spheres vascular lesion which is either inaccessible to sur- (Luessenhop, 1969) or Gelfoam fragments (Ishi- gery, or in which surgery could involve consider- mori et al., 1967). More recently, rapidly solidify- able haemorrhage, within the lesion itself or at a ing liquids have been prepared for embolisation. critical level. Thus, in the case of a vascular mal- We have consistently used fragments of Gelfoam, formation or tumour in the external carotid which is non-antigenic. These have the advantages territory, ligation or occlusion of feeding vessels of being relatively cheap and simple to handle and http://jnnp.bmj.com/ at some distance from the shunt or tumour bed prepare; their size can be finely adjusted to the has repeatedly been shown to result in the rapid individual case. Injection of even large fragments development of collateral supply; the placement is easy and does not require a large catheter. Al- of emboli within the pathological vessels them- though they appear to provide a satisfactory selves precludes this. thrombosis, we feel that a single fragment mis- In the external carotid territory embolisation placed in a vessel which it is not intended to may be useful in the management of angiomas: of embolise may be less harmful than a rigid metal the skin, tongue, bone, or dura mater; of arterio- or plastic sphere. The use of rapidly solidifying on September 26, 2021 by venous fistulae, eg caroticocavernous; and of liquids, although very effective, may produce a tumours: glomus tumours, angiofibromas, menin- more complete occlusion than is desirable of some giomas, or malignant tumours. Similar lesions of the tiny normal vessels arising from branches of the external carotid artery to supply the cranial nerves. 1 Address for reprint requests: Dr I. F. Moseley, The National Hospital, Queen Square, London WCIN 3BG. Preparation of the patient is important. If the Accepted 16 April 1977 external carotid artery is to be embolised, it is 937 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.40.10.937 on 1 October 1977. Downloaded from 938 Brian Kendall and Ivan Moseley essential that the patient should understand that vascular bed, emboli will pass directly through there is a risk of permanent neurological deficit, into the venous circulation; (ii) the size of the very minor though this may be; full informed vessels feeding the lesion and the volume of flow consent must, therefore, be given. The procedure within them: this will determine the size of the may be carried out under local or general anaes- emboli to be injected and the speed of the injec- thesia: the former has the advantage that the tion; (iii) the presence of anastomoses with the neurological state of the patient may be monitored internal carotid or vertebrobasilar trees, which continuously, the latter that pain on injection of will contraindicate embolisation; and (iv) the the external carotid artery branches, which may superselectivity of the catheterisation, and lack of cause the patient to move and impair the diag- reflux into the internal carotid or vertebral nostic quality of the radiographs, is avoided. circulations. Embolisation of a complex lesion may also be If the angiographic appearances are satisfactory a lengthy procedure. As a rule we use general for embolisation, small fragments of Gelfoam are anaesthesia. cut with fine scissors, the size depending on that The catheter through which embolisation is to of the vessels to be occluded, and suspended in be carried out may be introduced by direct exter- non-heparinised saline. The syringes which are nal or common carotid puncture, or by retrograde used for injecting the emboli are distinctively Seldinger catheterisation of the axillary or femoral marked, and are used for this purpose only. Just arteries. We use the last approach which has three before embolisation, and repeatedly during the main advantages: it is the one through which procedure, the catheter is inspected fluoroscopic- manipulation of the catheter is easiest, the ally to ensure that it has not moved. Ten to 20 operator's hands are kept far from the radiation emboli are then injected, followed by a small guest. Protected by copyright. field, and all the head and neck vessels may be quantity of contrast material to check fluoro- injected after a single arterial puncture. scopically that the vessel is still patent and that Adequate fluoroscopic and radiographic appara- reflux is not occurring. tus is also very important. We use a caesium This procedure is repeated, using progressively iodide image intensifier which can be used in the larger emboli, until it is clear at fluoroscopy that lateral position for fluoroscopy, and the angio- the flow in the catheterised vessel has slowed graphic series are carried out with 2 X or 3 X significantly. Another angiogram is then obtained. magnification, using a 0.2 mm focal spot tube. If this demonstrates almost complete occlusion of Any compromise on apparatus may prejudice the the pathological vessels, no further emboli are efficacy and safety of the procedure. injected; it is not the aim to achieve complete In adults we use the standard flexible, thin- blockage of the feeding vessel at this stage as this walled 5F gauge catheters, while in young child- may be hazardous. If there is no flow, marked ren, smaller tubing may be used. The first stage spasm, a proximal block, or obvious reflux, embo- of the procedure is filming of the carotid bifurca- lisation of that vessel is also terminated, for the tion to exclude ulcerating or stenosing atheroma, time being at least. followed by the documentation of the vascular Successful embolisation depends in part on pre- supply of the lesion to be embolised, and it is our ferential flow towards vascular lesions; when this practice to inject first those vessels of which em- is abolished, there is no force directing the emboli http://jnnp.bmj.com/ bolisation is unlikely to be possible-that is, the to their desired site. The same procedure is internal carotid and vertebral arteries. If most carried out until all the feeding vessels have been of the blood supply to the lesion arises from these dealt with, although with very extensive lesions it vessels, or if there are widely patent anastomoses may be necessary to carry out embolisation in between them and the external carotid branches, several stages. embolisation is not feasible (Figs. 1, 2). Some workers have suggested the injection of a Next, one of the external carotid artery sclerosant or thrombogenic agent at the end of branches supplying the lesion is catheterised; the embolisation of each vessel (Djindjian, 1977) on September 26, 2021 by lateral fluoroscopy is particularly useful during but we have not found this necessary. this superselective catheterisation. An angio- When embolisation appears complete, a flush graphic series is then performed and this is in- injection is made into the external carotid artery. spected before embolisation to determine: (i) the This will demonstrate any remaining vascular degree and nature of pathological vascularity- lesions, and in many cases, by reflux, confirm that that is, the presence or absence of significant the internal carotid artery remains normally arteriovenous shunting: if there is no pathological patent. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.40.10.937 on 1 October 1977. Downloaded from Therapeutic embolisation of the external carotid arterial tree 939 __V :t: :t A :b *YO:" __ _ *:w ,l <'w':, .....s' :.\4 j. V ,... a: .S ,: Fig. 1 Glomus jugulare *#0. tumour-vertebral angiogram. (All illustrations are lateral projections, subtracted, the right margin being anterior.) There is massive supply to the tumour (open arrowheads). External carotid supply was negligible, and the lesion was guest. Protected by copyright. not treated by embolisation. Arjo.I 0 Alwx :4 Ankow, .AV.wl " http://jnnp.bmj.com/ The following eight case reports illustrate the superior alveolus.