### Pressure Cooker Technique (PCT) in Endovascular Embolization

#### 1. What is the Pressure Cooker Technique (PCT)? The Pressure Cooker Technique (PCT) is an advanced endovascular embolization strategy used to improve the penetration of liquid embolic agents (e.g., Onyx, n-BCA) into high-flow vascular lesions while minimizing reflux and preventing non-target embolization.

It is particularly useful for treating: - Dural arteriovenous fistulas (dAVFs) - Arteriovenous malformations (AVMs) - High-flow fistulas in dural sinus malformations (tDSM)

By creating a proximal plug, the technique increases intravascular pressure, facilitating deeper and more controlled embolic delivery.

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#### 2. Why Use PCT? In high-flow vascular malformations, standard embolization techniques may lead to: - Poor penetration of embolic agents into the lesion. - Significant reflux of liquid embolic material into normal vessels. - Non-target embolization, risking ischemia or neurological damage. - Residual arteriovenous shunting, requiring repeat procedures.

PCT addresses these limitations by: ✅ Enhancing forward embolic penetration. ✅ Preventing reflux into normal arteries. ✅ Reducing the risk of embolization in unwanted areas. ✅ Allowing controlled occlusion of high-flow shunts.

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#### 3. How is the Pressure Cooker Technique Performed? PCT involves creating a temporary plug in the feeding artery using detachable coils, a balloon, or glue, before injecting the liquid embolic agent.

##### Step-by-Step Process: 1. Microcatheter Positioning:

1. A dual-lumen balloon catheter or a regular microcatheter is advanced into the arterial feeder of the fistula or AVM.

2. Proximal Plug Formation:

1. A detachable coil or glue (n-BCA) is deployed just proximal to the target embolization zone, forming a temporary plug.
2. This prevents proximal reflux of the embolic material.

3. Injection of Liquid Embolic Agent:

1. Onyx (ethylene vinyl alcohol copolymer) or n-BCA (n-butyl cyanoacrylate) is injected distally beyond the plug.
2. The embolic agent penetrates deeply into the vascular lesion.

4. Controlled Expansion & Deep Embolization:

1. The plug increases pressure distally, pushing the embolic agent deeper into the fistula or AVM nidus.
2. This enhances complete occlusion of the abnormal vascular network.

5. Final Catheter Removal:

1. After embolization, the catheter is gently withdrawn, leaving the embolic material in place.

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#### 4. Benefits of the Pressure Cooker Technique ✅ Improved Embolic Penetration - The plug forces the embolic agent deeper into the lesion rather than allowing it to reflux backward.

✅ Minimized Reflux - Prevents liquid embolic material from flowing retrogradely into normal arteries.

✅ Greater Safety in High-Flow Lesions - Reduces the risk of non-target embolization, which could lead to stroke or ischemia.

✅ Allows for Complete Occlusion - Helps achieve near-total closure of the arteriovenous shunt, reducing the likelihood of recurrence.

✅ Facilitates Multi-Stage Treatments - In cases requiring staged embolization, PCT ensures better control over successive interventions.

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#### 5. Clinical Applications PCT is widely used in complex neurovascular procedures, particularly in: - High-flow dural sinus malformations (tDSM) - Dural arteriovenous fistulas (dAVFs) - Brain and spinal AVMs - Carotid-cavernous fistulas (CCFs) - Congenital high-flow fistulas in neonates

It is especially beneficial in redo embolization cases, where previous treatments have left residual shunts.

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#### 6. Limitations & Risks 🚧 Catheter Entrapment - If Onyx solidifies too extensively around the catheter, removal may be difficult.

🚧 Risk of Vessel Rupture - High-pressure embolization may cause vascular rupture if not carefully controlled.

🚧 Technical Expertise Required - PCT is a complex technique requiring an experienced neurointerventionalist.

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### 7. Conclusion The Pressure Cooker Technique (PCT) is a powerful embolization strategy for high-flow neurovascular malformations, significantly improving embolic agent delivery while reducing reflux and enhancing safety. It is particularly valuable in redo embolization cases of dural sinus malformations (tDSM) with high-flow fistulas.

Would you like a comparison of PCT with other embolization techniques, such as dual-lumen balloon-assisted embolization?