Cap And Onyx For Aneurysmal Filling

Cellulose acetate polymer (CAP) solution is a new Japanese liquid embolic material dissolved in DMSO that has been used clinically for the thrombosis of cerebral aneurysms (46) and has been shown to be a safe and useful embolic agent for arteriovenous malformations (AVMs) (47). Longer-term follow-up studies are required to better evaluate the clinical safety and effectiveness of this solution. CAP was associated with complications, including aneurysmal rupture and parent-artery stenosis, as well as strong chemical corrosion, which led to acute chemical damage of the aneurysmal wall and inflammatory cell infiltration (48).

Onyx, another liquid embolic polymer based on CAP, has been proposed as an alternative treatment for aneurysms and AVMs. It is a biocompatible, nonadhesive liquid polymer that, upon contact with blood, precipitates and solidifies to form a soft and spongy embolus. One study achieved complete aneurysmal occlusion in 79% of cases and subtotal occlusion in 13%. Aneurysmal occlusion rates were concluded to be superior to those for coil occlusion, and treatment morbidity rates were comparable to those for coil occlusion (49). Another study reported good results in the treatment of 23 patients with AVMs (50).

Like CAP, Onyx is not without its drawbacks. An important limitation is the poor control of migration of Onyx into the parent artery. The use of assistance devices, such as microcoils, microstents, and balloons, help to achieve faster and more complete filling of the aneurysm with Onyx but do not completely preclude intractable migration of Onyx into the parent artery (51). Cases of transient and permanent neurologic deficits, SAH, massive reflux of Onyx into the afferent artery peduncle (52), and incomplete filling of the aneurysmal sac (52,53) have also been reported. Additionally, imaging of Onyx on MR and CT presented some challenges. Onyx appears hypointense on MR images, interferes with MRA in patients with stents, and creates artifacts that hinder CT evaluation (53). These disadvantages must be overcome before Onyx can play a greater role in endovascular treatment.

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