Interventional Neuroradiology

contrast medium that not only opacifies the mixture (it is highly radio-opaque) but also slows polymerization. A ratio of 80% glue:20% oil polymerizes very rapidly and such a concentration would only be used in high-flow fistulas. Common concentrations used are 30-60% glue. Flow-guided catheters or over-the-wire catheters can be used. The goal is to occlude the nidus without obstructing venous outflow, which can cause hemorrhage or reflux-ing into normal vessels.

Once the glue has been injected, the catheter is rapidly pulled or removed to prevent it being glued in place. The catheter is flushed with 5% dextrose to prevent polymerization of glue in the catheter prior to glue injection. Glue embolization is thought to be permanent (Fig. 19.3).

Onyx is a liquid agent increasingly used instead of glue. It consists of ethylene vinyl alcohol copolymer dissolved in the solvent DMSO. It has the advantage of solidifying slowly, allowing better penetration of the nidus. Other agents, such as polyvinyl alcohol particles, silk sutures or micro-coils, are very effective but are strictly for use pre-surgery, as AVMs recanalize after use of these agents.

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