脑动静脉畸形的栓塞相对于脑动脉瘤栓塞而言，于我而言是个更难的技术。做动脉瘤栓塞就是“顺藤摸瓜”，大多数动脉瘤的解剖结构很好理解，容易做出合理的方案。但是脑动静脉畸形不一样，结构上千差万别，所以治疗相对而言个体化很强，治疗方法不是千篇一律的。
NBCA胶是一种粘性的胶，注射时间长后，微导管容易滞留于体内，要求医生要眼疾手快。应用NBCA胶，了解一些操作技巧非常必要。国外的参考书往往描述这些操作的细节会更多。下面的这个部分，描写NBCA栓塞技术非常好，摘录下来和大家分享。我将中英文对照地放在一起，英文好的同行，阅读原文估计更有韵味。
以下内容选自《Handbook of Cerebrovascular Disease and Neurointerventional Technique》。
N-BCA glue embolization technique
NBCA栓塞技术
(e) When a flow-directed or over-the-wire type microcatheter is in the desired position,beyond branches to normal brain, and any provocative testing has been completedand suggests that it is safe, then embolization can proceed.
当微导管头端到达靶点位置，远端无正常脑组织分支，行provocative试验证明此处注射栓塞剂安全，就可以开始栓塞了。
(f) When using glue, all persons near the sterile field should wear glasses or other eyeprotection. If a connection comes loose during injection, the glue can sprayand stick to whatever it touches.
注射胶时，无菌区域附近的所有人均需要佩戴眼镜或其他眼镜保护装置。如果注射时接头处松动，胶可能飞溅并凝结于所接触的任何东西。
(g) Double-check the superselective arteriogram performed at that catheter position, and check how long the contrast takes to reach the lesion.
应用超选造影二次确认导管头端位置，并且计算造影剂到达病变的时间。
(h) As a rule of thumb, if that time is under one second, at least a 70% glue mixture (three parts nBCA to one part Ethiodol?) is required. Over 2 s requires a 50% (one nBCA to one Ethiodol) or more dilute mixture.
如果到达时间在1s内，至少需要70%的胶浓度（3份NBCA加1份碘油）。如果大于2s，需要50%胶（1份NBCA加1份碘油）或更稀浓度。
(i) Tantalum powder greatly increases the radio-opacity of glue, but is not absolutely necessary unless the glue mixture is greater than 70% n-BCA. Tantalum is messy and can clump, so most practitioners rarely use it.
钽粉能过明显增加胶的显影，但并不是必须的，除非胶的浓度大于70%。钽粉可能凝结成块，所以大多数医生几乎不用。
(j) Draw up theTrufill? n-BCA (Cordis Neurovascular, Miami Lakes, FL) from its tube using a labeled, glue-compatible 3-mL syringe (avoid polycarbonate plastic…it softens).
应用有刻度，与胶相容的3ml注射器从盛胶的小管内抽出胶。
(k) Draw up the Ethiodol? in a labeled syringe, and add the proper volume to the glue syringeto achieve the desired concentration.
用有刻度的注射器抽出碘油，加入胶中，以配成想要的浓度。
(l) Have several labeled 3-mL syringes filled with 5% dextrose solution ready.
多管3ml注射器充满5%葡萄糖。
(m) Carefully pull back slightly on the microcatheter to remove any slack, and slightly loosen the rotating hemostatic valve so that it just barely prevents back-flow of blood in the guiding catheter, without binding the microcatheter too tightly.
轻轻回拉微导管使微导管的松弛部分变得略紧；轻轻松动Y型阀的止水阀门，使可以刚好阻止血液回流，同时避免将微导管限制过紧。
(n) Re-confirm proper catheter positioning with a contrast injection via the microcatheter for a superselective arteriogram. Select a projection that shows the microcathete rtip and its relationship to any curves in the arterial feeder distal to the catheter tip, any normal branches proximal to it, and the lesion.
通过微导管超选造影再次确认微导管头端位置正确。选择合适的工作角度，能同时显示微导管头端以及显示微导管头端远端的供血动脉的弯曲，头端近端的正常分支，以及能显示病变。
(o) Study the superselective arteriogram carefully to time the arteriovenous transit, and to determine the morphology of the target arterial feeder and nidus structure where the liquid agent will be injected.
仔细分析超选造影时从动脉到静脉的通过实践，分析靶动脉的形态学结构以及胶可能到达处的畸形血管团的结构。
(p) Attach a glue-compatible stopcock directly to the microcatheter. Cook Medical(Bloomington, IN) makes a high-pressure, white nylon plastic one, and three-way stopcocks with Luer lock fittings that hold up well during glue injections.
将一个与胶相容的连接头或三通连接到微导管。
(q) One way stopcocks are sufficient, but three way are preferred since they allow a flush syringe of dextrose to remain attached even when the glue syringe is attached.This works well for doing the push technique (see below).
单向连接头往往足够，如果需要连接有充满葡萄糖的注射器时需要三通。使用推送技术的时候需要。
(r) Thoroughly flush the microcatheter with 5% dextrose solution. Generally, approximately 5–10 mL is sufficient to clear all saline and/or blood from the microcatheter lumen.
用5%葡糖糖溶液充分冲洗微导管。一般而言，大约5-10ml葡萄糖足够从微导管腔冲洗干净生理盐水和血液。
(s) As the last milliliter of dextrose is being injected, close the stopcock to prevent blood backflow into the microcatheter.
注射完葡萄糖溶液后，关上三通开关，组织血液在微导管内的回流。
(t) Holding the stopcock upright, fill the Luer-lock connection fully with dextrose.
将三通朝上，其内充满葡萄糖溶液。
(u) Create a blank roadmap mask, the glue injection can be well visualized under digital subtraction.
踩出空白路图，这样在屏幕上可清楚显影注入的胶。
(v) Attach a 3-mL syringe loaded with the prepared glue mixture.
将准备好的胶的3ml注射器连接上。
(w) For continuous column technique, slowly, but steadily inject the glue using roadmap imaging, such that the glue column is continuously moving forward.
连续注射技术时，在路图下缓慢但持续注入胶，使胶持续向前移动。
(x) Fill the arterial feeder and as much of the nidus as possible.
用胶填充供血动脉和尽可能多地填塞畸形血管团。
(y) Be alert for any signs of reflux of glue back along the catheter, passage of glue into thevein, or reflux of glue from the nidus into other arterial branches feeding thelesion.
注意胶沿微导管返流，胶进入静脉，以及胶从畸形血管团返流至其他供血动脉分支的任何征象。
(z) If any of these conditions is occurring and one is using dilute glue, one might be able to briefly pause the injection, then resume cautiously. Sometimes the glue will find another pathway through the nidus.
如果上述征象发生，并且用的是低浓度的胶，可短暂停止注射后，再小心重新注射。有时候可见胶进入畸形团的其他部位。
(aa) The glue injection is relatively quick, but controlled. Polymerization usually occurs within a few seconds.
胶的注射相对较快，但是可控的。多在几秒内发生凝固。
(bb) The embolic agent should be deposited in the “safety zone” consisting of AVM nidus and only the artery beyond all normal branches, and vein before other venous inputs beyond the occluded nidus. (See Fig. 7.1)
胶必须注射在“安全区域”，这些区域包括：畸形血管团，正常分支远端的动脉端，畸形血管团远端无其他回流静脉进入的静脉端。（见图1）
(cc) If there is any question that the glue is refluxing or going somewhere it shouldn’t, or if finished filling the desired space with glue, stop injecting, aspirate the syringe to create negative pressure in the microcatheter, and quickly, smoothly withdraw the microcatheter completely from the patient and discard it. It is best to pull the guiding catheter and microcatheter as a unit, but, sometimes,using braided microcatheters, one can remove it by just pulling the microcatheter.
如果有胶的返流，或胶进入了不该进入的部位，或者已经填塞了计划填塞的部位，就停止注射，抽吸注射器使微导管内形成负压，并快速、轻巧地将微导管完全拔出丢弃。最好将导引导管和微导管作为一个整体拔出，但用编织微导管时，可仅拔除微导管。
(dd) Examine the rotating hemostatic valve of the guiding catheter for any retained droplets of glue, then aspirate and double flush the stopcock, rotating hemostatic valve,and guide-catheter.
检查导引导管的Y型阀有无残留的胶的颗粒，抽吸和两次冲洗连接头，止水阀和导引导管。
(ee) Once the guide catheter is thoroughly inspected and flushed, re-insert it to the arterial territory of interest, and perform a follow-up arteriogram to ensure that the desired result is obtained.
如导引导管充分检查和冲洗后，再将导引导管放置于治疗动脉内，造影，检查栓塞效果。
(ff) The wedged technique is similar to the full-column technique, except that the microcatheter tip is wedged in the nidus or small vessel and much more dilute glue can be used.
楔塞技术与连续注射技术类似，区别就在于前者的微导管头端楔入畸形血管团或小的血管内，这种情况下可以用更稀的胶。
(gg) In wedged position, very slow, prolonged injections with dilute glue (less than 30% glue)can be done over several minutes (which seems like hours).
在楔入的部位，可以用很稀的胶（小于30%）缓慢注射，可以注射几分钟。
(hh) When glue begins to enter the vein, or to reflux along the microcatheter, one should stop injecting, wait a minute for polymerization, aspirate back from the gluesyringe, then pull the catheter out.
当胶开始进入静脉，或沿微导管返流，必须停止注射，使凝固，抽吸注射器，拔除微导管。
(ii) Using the push technique, the microcatheter is generally some distance proximal to the lesion, but still beyond normal brain vessels.
应用推送技术时，微导管头端常距病变有些距离，但是仍在正常脑供血血管远端。
(jj) When ready to embolize, the microcatheter is flushed with dextrose solution.
准备注射前，微导管已用葡萄糖溶液冲洗。
(kk) A three way stopcock is attached to the hub of the microcatheter, and a syringe of 5% dextrose flush is attached to one connection, and the appropriately mixed glue to another.
三通连接微导管的尾端连接部，三通的一头接5%葡萄糖注射器，一头接盛胶的注射器。
(ll) Depending on the size of the vessel being embolized, 0.1–0.2 mL of glue mixture is injected into the microcatheter, the stopcock is turned and, under roadmap visualization, the glue is flushed into the vessel using the dextrose flush syringe.
根据栓塞血管的直径，0.1-0.2ml胶注入微导管后，旋转三通，在路图透下，胶用葡萄糖溶液冲洗入血管内。
(mm) Generally, it is advisable to pull the microcatheter at this point. The exception would be when the glue bolus travels quite distal to the tip of the microcatheter, and if contrast injections via the guide catheter confirm persistent patency of the feeding vessel being embolized. A second glue bolus may be injected and pushed with dextrose as long as the microcatheter remains patent.
通常此时就要拔除微导管。除非胶的团块漂至微导管头端很远的位置，以及通过导引导管的造影证实供血动脉仍通畅时，不拔管。如微导管仍通畅，第二次注入胶，并用葡萄糖溶液冲至远端。
(nn) The dribble technique is similar to the full column technique, except that the glue is injected very, very slowly, to allow the blood flow to fragment the glue and form small particles. These tend to travel along with the blood flow until they impact on a small nidus or capillary bed.
滴注技术类似于连续注射技术，胶注射得非常非常慢，使血流能使胶破碎成小颗粒。这些小颗粒顺着血流，闭塞于很小的畸形团或毛细血管床。
(oo) Glueembolization techniques are illustrated in Fig. 7.2.
胶的栓塞技术在图2中表示。
图1 AVM栓塞的安全区域
斜线部分和畸形血管团是安全区域
图2 AVM胶栓塞的四种技术
Full Column Technique 连续注射技术
Wedged Technique 楔塞技术
Push Technique 推送技术
Dribble Techque 滴注技术
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