Abstract Number ‐ 197: A Single‐Center, 23‐Year Experience with the MAGIC Catheter for Pediatric AVM
Authors: Bazil Maximilian J , Philbrick Brandon , Shigematsu Tomoyoshi , Berenstein Alejandro , Fifi Johanna 
Published: April 2023

Introduction
The MAGIC Catheter (Balt, Montmorency, France) is a commonly used flow‐directed microcatheter for neuro‐interventions. Despite the MAGIC catheter not having FDA approval for use in pediatric and neonatal populations, our institution has used this catheter off‐label for numerous cases of pediatric arteriovenous malformation (AVM), vein of Galen malformation (VOGM), dural arteriovenous fistula (dAVF), and pial AVF (pAVF). Herein, we outline our practice’s experience with the MAGIC catheter for pediatrics.

Methods
We reviewed our institutional, quality‐control database for all cases of pediatric, vascular malformation that utilized the MAGIC catheter since its original use in pediatrics at our practice (March 1999) and July 2022. We describe the disease and demographic characteristics of this cohort, frequency of MAGIC catheter use, adjunct supplies, complications, smallest vessels catheterized, and clinical outcomes.

Results
Over the review period, 99 pediatric patients with AVM(45), VOGM(49), dAVF(3), and pAVF(2) were identified for detailed review. This cohort has collectively undergone 194 procedures. The average age at first procedure with the MAGIC catheter was 4.42 years with a wide variation (SD: 4.56; Range: 0–17.64). The majority of cases using the MAGIC catheter were cerebral angiograms with embolization (190 – 97.9%), though occasionally it was employed for angiography alone (4 – 2.1%). A 4‐Fr Berenstein Catheter was the most common adjunct catheter used during the study period (156/194; 80.4%), though the 5‐Fr Envoy appeared often as well (30/194; 15.5%). Every embolization in the series led to interval‐decrease or cure of the malformation, though five intraprocedural complications were noted in the form of transient decrease neuromonitoring evoked potentials, epidural hematoma due to vessel perforation, and three cases of vessel perforation without long‐term consequence. Periprocedural complications occurred in one patient involving an intraventricular hemorrhage requiring a ventriculoperitoneal shunt. The most common liquid embolic agent used with the MAGIC catheter was nBCA (179/190; 94.2%) with occasional use of Onyx 18, Fibered Coils, Surgi‐Flo, STS, and Ethanol. Of the 67 patients who had a follow‐up available for review, 30 (44.8%) are neurologically intact and clinically well, 19(28.4%) are clinically well with mild symptoms (mild autism spectrum disorder, mild hemiparesis, headaches, mild weakness, post‐hemorrhage/stroke excellent recovery), 9 (13.4%)have experienced moderate to severe symptoms (limb weakness, cranial neuropathies, cognitive delay/deficit, inability to ambulate, seizures), 3 (4.5%) have passed away, and 6 (9.0%) have been lost to follow‐up. Selective catheterization of small vessels was performed among the anterior choroidal, thalamoperforator, posterior choroidal, middle meningeal arteries and superior cerebellar, posterior cerebral, and deep external/internal carotid artery branches, and many others by the MAGIC microcatheter for contrast injection or delivery of embolic agents.

Conclusions
Flow‐directed microcatheters are a quintessential tool used in the endovascular treatment of cerebrovascular diseases, but few have regulatory approval for use in pediatric populations. The off‐label use of the MAGIC microcatheter has been shown to be safe and effective in pediatric embolization procedures. However, there still remains a technology gap in the development of flow‐directed catheters specifically designed and proportioned for use in pediatric patients.