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      <h1 class="highwire-cite-title" id="page-title">Regarding “Embolization of Intracranial Dural Arteriovenous Fistulas Using PHIL Liquid Embolic Agent in 26 Patients: A Multicenter Study”</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">V. Bhatia</span>, <span class="highwire-citation-author" data-delta="1">A. Kumar</span> and <span class="highwire-citation-author" data-delta="2">N. Khandelwal</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">June 2017,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">38 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(6) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E38; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A5142 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-54743--6855866785" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">V. Bhatia </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Radiodiagnosis
Postgraduate Institute of Medical Education and Research
Chandigarh, India</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=V.%2BBhatia%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Bhatia%20V&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AV.%2BBhatia%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0003-3700-8025" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for V. Bhatia</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">A. Kumar </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Radiodiagnosis
Postgraduate Institute of Medical Education and Research
Chandigarh, India</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=A.%2BKumar%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Kumar%20A&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AA.%2BKumar%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0002-8267-7220" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for A. Kumar</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">N. Khandelwal </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Radiodiagnosis
Postgraduate Institute of Medical Education and Research
Chandigarh, India</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=N.%2BKhandelwal%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Khandelwal%20N&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AN.%2BKhandelwal%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0002-8326-5164" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for N. Khandelwal</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">We read the article by Lamin et al<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> with considerable interest. They have highlighted their valuable experience with Precipitating Hydrophobic Injectable Liquid (PHIL; MicroVention, Tustin, California) embolic agent in the management of dural AVFs. We agree with their observations that the use of PHIL is safe and effective for endovascular management of dural AVFs, with outcomes comparable with those of Onyx (Covidien, Irvine, California).</p><p id="p-2">A few points are worth mentioning. The advantages of PHIL over Onyx as they mentioned are the lack of any prior preparation, fewer beam-hardening artifacts, and less adhesiveness, leading to better forward penetration.<sup><a id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1</a></sup></p><p id="p-3">Another advantage of PHIL over Onyx is seen when MR imaging is used on follow-up. Onyx causes susceptibility artifacts on gradient and susceptibility-weighted images, which are not seen with PHIL.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup></p><p id="p-4">Plug formation with PHIL is faster than with Onyx due to fewer layering effects, resulting in reduced fluoroscopy time and consequent radiation dose.<sup><a id="xref-ref-2-2" class="xref-bibr" href="#ref-2">2</a></sup> There is minimal wastage with PHIL because it comes in a prefilled syringe in contrast to Onyx.</p><p id="p-5">Failed embolization with subsequent requirement of an operation or combined endovascular and surgical management for dural AVFs has also been reported in previous studies. The authors of this study did not experience this failure; however, it has been shown that Onyx forms a continuous smooth-surfaced column within vessels, while PHIL forms a rough-surfaced column interspersed with blood clots. Careful surgical handling of the vessel with low-voltage bipolar cautery to maintain vessel wall integrity is required with the PHIL embolic agent.<sup><a id="xref-ref-2-3" class="xref-bibr" href="#ref-2">2</a></sup></p><p id="p-6">We have made similar observations with PHIL at our institution and have found it to be an effective embolic agent in the management of intracranial AVFs as observed in the current study.</p><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-38.6.E38.1" data-doi="10.3174/ajnr.A5037"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Lamin</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Chew</span>  <span class="cit-name-given-names">HS</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Chavda</span>  <span class="cit-name-given-names">S</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Embolization of intracranial dural arteriovenous fistulas using PHIL liquid embolic agent in 26 patients: a multicenter study</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2017</span>;<span class="cit-vol">38</span>:<span class="cit-fpage">127</span>–<span class="cit-lpage">31</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.3174/ajnr.A5037</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>27932510</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzOC8xLzEyNyI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zOC82L0UzOC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-38.6.E38.2" data-doi="10.5152/dir.2015.15283"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Koçer</span>  <span class="cit-name-given-names">N</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Hanımoğlu</span>  <span class="cit-name-given-names">H</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Batur</span>  <span class="cit-name-given-names">Ş</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Preliminary experience with precipitating hydrophobic injectable liquid in brain arteriovenous malformations</span>. <abbr class="cit-jnl-abbrev">Diagn Interv Radiol</abbr> <span class="cit-pub-date">2016</span>;<span class="cit-vol">22</span>:<span class="cit-fpage">184</span>–<span class="cit-lpage">89</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.5152/dir.2015.15283</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>26782157</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.5152/dir.2015.15283&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=26782157&amp;link_type=MED&amp;atom=%2Fajnr%2F38%2F6%2FE38.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2017 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 38</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 6 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Jun 2017 </div></div>
      
      
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