Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus

Unexpected coil mass migration during transvenous embolization of a dural arteriovenous fistula resolved with guidewire-assisted snaring technique

Endovascular embolization is a standard treatment for dural arteriovenous fistulas (dAVFs). Although it is considered relatively safe, intraoperative and postoperative complications can occur. Herein, a rare case of unexpected coil mass migration requiring a retrieval procedure during sinus occlusion for a transverse-sigmoid sinus dAVF (TSdAVF) is described. An 83-year-old man presented with worsening decline in cognitive function. Magnetic resonance angiography showed a TSdAVF. Since his symptoms seemed to be a result of the TSdAVF, transvenous embolization preserving the normal cranial venous circulation was planned. During sinus occlusion, including embolization of the shunted pouch of the TSdAVF, unexpected migration of the coil mass to the confluence of the superior sagittal sinus and the transverse sinus occurred. The migrated coil mass impeded venous circulation in the superior sagittal sinus. Since the presence of the coil mass at the confluence could have had catastrophic sequelae, the coil mass was retrieved using a guidewire-assisted snaring technique. Sinus occlusion was subsequently completed with repositioning of the coil mass at the target site. The TSdAVF resolved, with no recurrence confirmed for 1 year. Clinicians should be aware that coil mass migration can unexpectedly occur during sinus occlusion performed for treatment of a TSdAVF. The guidewire-assisted snaring technique might be effective in resolving this intraoperative complication.

Transarterial embolization of sinus dural arteriovenous fistula using non-adhesive liquid embolic material

Objective: The objective is to report our experience of transarterial embolization of sinus dural arteriovenous fistula (DAVF) using non-adhesive liquid embolic material.Materials and methods: In 3 cases of Borden type II sinus DAVFs, a Copernic balloon was used to protect sagittal sinus in one patient, palliative Onyx embolization was performed to protect transverse sinus in one patient and EVAL/DMSO/ethanol mixture (EVAL, SUCCESS, Shandong, China) was used in the last patient.Results: Two Borden type II DAVFs were changed into type I DAVF and one was cured. The dural sinus was patent after successful Onyx embolization in 3 cases resulting in well patient recovery. There were no treatment-related events.Conclusion: Transarterial embolization of sinus DAVF using non-adhesive liquid embolic material could be effective and safe with sinus protection techniques.

ihtObtura: A novel liquid embolic agent with post-embolization radiopacity loss, in endovascular treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and tumors: CLARIDAD trial

BACKGROUND

Endovascular embolization is frequently used for vascular lesions of the head and neck. Newer agents may help to enhance visualization and improve treatment outcomes.

METHODS

The CLARIDAD clinical trial was a prospective, single center, first-in-man investigation of neurovascular embolization using the novel embolic agent ihtObtura for a broad indication, covering the need for a liquid embolic agent in head and neck procedures. The primary outcomes assessed were therapeutic efficacy to deliver ihtObtura to embolize the catheterized pedicle and associated angiographic vascularity, and subsequent loss of radiopacity. Safety endpoints included procedural adverse events, modified Rankin Scale (mRS) score, morbidity, and mortality. Radiologic and clinical follow-up evaluations were conducted at 30, 90, 180 days, and 1 year post-treatment.

RESULTS

65 consecutive patients (mean age 37.8 years, 50.8% women) were treated over 129 sessions. A total of 42 brain arteriovenous malformations (AVMs; 90% grades III and IV), 8 dural arteriovenous fistulas (DAVFs), and 15 hypervascular tumors were treated with ihtObtura using an average of 3.9 mL per session and 7.7 mL per patient. We achieved therapeutic effectiveness in 99% of catheterizations. Radiopacity loss was complete after 74.3% of the sessions at 30 days, 95.6% at 90 days, and 100% at the 1 year follow-up. Serious adverse events (mRS score >2) occurred in two patients (3.1%) with previously ruptured high grade AVMs leading to one death and one permanent disabling morbidity.

CONCLUSIONS

The study showed that ihtObtura was a novel, safe, and effective liquid embolic agent for the treatment of AVMs, DAVFs, and hypervascular tumors. Its key property of significant radiopacity loss contributes to improve anatomical understanding, particularly in staged procedures, as well as reduction in post-procedural imaging artifact. There may be additional benefits of eliminating tantalum from the embolic mixture in terms of lesion penetration.

Single Centre Initial Experience with the Scepter Mini Balloon Microcatheter

BACKGROUND

The use of balloon microcatheters in interventional neuroradiology is well documented. However, their use is sometimes limited by the small diameter and excessive tortuosity of the vasculature. The Scepter Mini dual-lumen balloon microcatheter (SMBM) (Microvention, Aliso Viejo, CA) has been designed to address these challenges by decreasing the distal catheter profile, allowing distal access to the target vessel.

METHODS

This is a single-centre retrospective analysis of the initial cases performed using the Scepter Mini balloon microcatheter. The targeted conditions were vascular malformations. Patient clinical data, angiographic features of the vascular abnormalities and operation reports were reviewed and the procedural parameters, radiation doses, occlusion rates and complications were assessed.

RESULTS

A total of 15 SMBM were used in 11 cases. In all cases the procedure performed was balloon inflation and antegrade delivery of precipitating hydrophobic injectable liquid (PHIL) (Microvention, Aliso Viejo, CA) for embolisation of a targeted feeding vessel and cranial and spinal vascular malformations. Successful feeding vessel distal access and antegrade liquid embolisation was achieved in 100% of the cases. One of the 11 cases was an emergency procedure. One procedural target vessel rupture, likely due to overinflation, and three minor post-procedure complications were observed.

CONCLUSION

The SMBM represents a significant advance in the treatment of cerebrospinal vascular malformations, allowing balloon catheter access into tortuous and small calibre vessels.

Transvenous Onyx embolization for dural arteriovenous fistula with concomitant transvenous balloon protection of the venous sinus

BACKGROUND

The purpose of this study was to evaluate the technical efficacy and safety of transvenous Onyx embolization for dural arteriovenous fistulas (DAVFs) with concomitant transvenous balloon protection of the venous sinus when transarterial route failed or was not feasible.

METHODS

Between September 2010 and December 2016, thirty-six patients presenting with intracranial DAVFs underwent transvenous balloon-assisted Onyx embolization. The technical efficacy, treatment-related complications, and angiographic and clinical outcomes were reviewed from our prospectively maintained DAVF database.

RESULTS

According to the Cognard Classification, 11 patients presented with clinically symptomatic Cognard type I; 11 cases with Cognard type IIa; 10 cases with Cognard type IIb; and 4 cases with Cognard type IIa+b. Complete angiographic occlusion of the DAVFs at the latest follow-up (mean 18 months after transvenous embolization) was achieved in 28 patients (77.8%), near-complete angiographic occlusion with minimal residual fistula in 5 patients (13.9%) and significant flow reduction of the DAVF in 2 patients (5.6%) and residual fistula for further treatment in 1 (2.8%) patient. Total clinical cure or remission of the pretreatment symptoms was achieved in 31 patients (31/36, 86.1%; 26 and 5 cases respectively). Affected venous sinus was preserved in 28 patients, intentionally occluded in 7 patients and gradually occluded in 1 patient. There were no immediate or long-term persistent complications after treatment.

CONCLUSIONS

Transvenous Onyx embolization of dural arteriovenous fistulas with combined transvenous balloon protection of the venous sinus is safe and effective in achieving high occlusion rate, low embolization-related complications and satisfactory clinical outcomes.

Hairball-Like Migration of "Onyx Threads" into the Draining Vein during Transarterial Embolization of a Dural Arteriovenous Fistula: A Case Report and Experimental Validation

Transarterial embolization using Onyx is a well-established treatment for dural arteriovenous fistulas (DAVFs). However, complications can arise when Onyx migrates into the venous side, impairing the draining veins. We encountered a case where Onyx, injected through the arterial side, strayed into the jugular vein, forming a hairball-like structure. Our study aimed to investigate the underlying mechanism of this unusual phenomenon. We postulated that Onyx precipitates into thread-like shapes when passing through extremely narrow openings. To test this, we extruded Onyx from a syringe through a 27-gauge needle into a silicone tube with flowing water. By varying the flow speed, we observed the hardening behavior of Onyx. Under slow flow, the extruded Onyx quickly solidified at the needle tip, forming a round mass. Conversely, high-speed flow resulted in Onyx being dispersed as small pieces. We successfully replicated the formation of "Onyx threads" under continuous slow flow conditions, similar to our case. This phenomenon occurs when Onyx unexpectedly migrates to the draining vein through a tiny opening during transarterial embolization for arteriovenous shunt diseases. Early recognition and appropriate measures are necessary to prevent occlusive complications in the draining veins and the pulmonary system.

Safety and efficacy of dual lumen balloon catheters for the Treatment of cerebral vascular malformations: A systematic review, pooled analysis, and meta-analysis

BACKGROUND

There is little evidence in scientific literature assessing the safety and efficacy of dual-lumen balloon catheters (DLBCs) and their performance compared to single-lumen catheters (SLCs).

METHODS

In this PROSPERO-registered, PRISMA-compliant systematic review, we identified all MEDLINE and EMBASE single-arm (DLBCs) and double-arm (DLBCs vs SLCs) cohorts where DLBCs were used for the treatment of cerebral arteriovenous malformations (AVMs) or dural arteriovenous fistulas (dAVFs). Immediate angiographic outcome, vascular complications, technical failures, reflux episodes and entrapment were the primary outcomes. A meta-analysis of the double-arm studies summarized the primary outcomes of total procedural time and immediate angiographic outcome.

RESULTS

The authors identified 18 studies encompassing 209 treated lesions with reported outcomes. Complete occlusion was achieved in 108/132 treated dAVFs (81.8%, 95% CI: [74-87.8%]) and in 45/77 treated AVMs (58.4%, [46.7-69.4%]). The proportion of completely occluded dAVFs was statistically significantly higher than that of AVMs, p < .001. There were eight reported vascular complications (3.8%, [1.8-7.7%]), five technical failures (2.4%, [0.9-5.8%]), 14 reflux events (6.7%, [3.9-11.2%]), two entrapment events (1%, [0.2-3.8%]) and 0 deaths (mortality rate 0%, [0-2.3%]). In a meta-analysis for the treatment of dAVFs, the total procedural time was significantly less for DLBCs compared to SLCs (64.9 vs 125.7 min, p < .0001). The odds of complete immediate occlusion were significantly higher with DLBCs compared to SLCs (odds ratio (OR) 4.6, [1.5-14.3], p = .008).

CONCLUSION

Dual-lumen balloon catheters are safe and effective for the embolization of cerebral AVMs and dAVFs and can achieve faster and potentially superior results compared to SLCs.

REGISTRATION-URL

https://www.crd.york.ac.uk/prospero/ Unique Identifier: CRD42021269096.

Torcular dural AVF: Transvenous onyx embolisation with sinus reconstruction

Transvenous onyx (Microtherapeutics, Irvine, CA, USA) embolization with sinus reconstruction using a venous balloon is a novel technique to embolise dural arterial venous fistula while preserving the sinus. We elucidate the technical tips and tricks that were employed to treat this torcular dural AVF in an elderly male with visual disturbances secondary to papilledema. Right external carotid artery injection revealed a type 2c fistula along the torcula with feeders from the right parietal & petrosal branches of the middle meningeal artery and dural branches of the posterior auricular and the occipital artery. The right distal transverse and the sigmoid were occluded with retrograde flow into the superior sagittal sinus and the cortical veins. XPER CTA analysis revealed the fistula point to be along the wall of the torcula. Through right femoral artery access, a neuron max (Penumbra inc.USA) was placed in the right common carotid artery. An eclipse (Balt Extrusion, France) 6 × 12 mm single lumen balloon was placed in the proximal ECA to achieve flow reduction. Thereafter, through bilateral femoral venous approach, two neuron max 8 F (Penumbra inc.USA) were placed into the left jugular vein. A Copernic RC balloon 10×80 mm (Balt Extrusion, France) was placed from the left to the right transverse sinus. Further, two microcatheters, 1.5 F Marathon (Medtronic, Minneapolis, MI, USA) were navigated into the feeding arteries from the venous end. Microcatheter injections were taken with inflation of the venous balloon to determine the point at which sinus and cortical vein reflux is absent. Following that onyx 18 was injected under biplane fluoroscopy with an adequately inflated arterial and venous balloon. We could achieve retrograde permeation of the onyx into the fistula and the arterial feeders resulting in complete occlusion while preserving the sinus. Careful analysis of the angioarchitecture of the fistula and evaluating for delayed cerebral venous drainage is the key to determining the right strategy to achieve complete occlusion of the fistula.

Balloon protection of the vein of Labbé during embolisation of a dural arteriovenous fistula

We describe a novel technique of vein of Labbé preservation using balloon protection during embolisation of a transverse-sigmoid sinus dural arteriovenous fistula. A patient with refractory Cognard type IV fistula of the left transverse-sigmoid sinus and persistent pulsatile tinnitus underwent successful embolisation of the lesion via transarterial route. During embolisation, a dual lumen balloon was simultaneously inflated within the vein of Labbé, at its orifice in the transverse-sigmoid sinus junction, to prevent embolic reflux. This allowed for liquid embolic embolisation of the fistula via the transarterial route resulting in complete occlusion. The patient recovered well with marked improvement of his tinnitus.

Angioarchitectural Analysis of Arteriovenous Shunts in Dural Arteriovenous Fistulas and Its Clinical Implications

BACKGROUND

Detailed understanding of the angioarchitecture of arteriovenous shunts in dural arteriovenous fistulas (DAVFs) is essential when planning endovascular treatment.

OBJECTIVE

To analyze shunt patterns and their clinical implications in transverse-sigmoid sinus and superior sagittal sinus DAVFs.

METHODS

A total of 48 DAVFs treated with endovascular embolization between January 2010 and June 2021 were investigated. The preprocedural and intraprocedural digital subtraction angiograms were examined to characterize the shunt patterns of DAVFs in terms of anatomic relations to the sinuses and cortical veins. Treatment characteristics and outcomes were evaluated.

RESULTS

The shunt patterns were categorized into 4 types: the direct sinus fistula (n = 8/48, 16.7%), compartmental sinus channel (n = 14/48, 29.1%), mural channel (n = 13/48, 27.1%), and bridging vein shunt (n = 13/48, 27.1%). Mural channel lesions revealed direct (n = 4/13, 30.8%) and indirect (n = 6/13, 46.2%) cortical venous connections. Multiple shunt types were seen in 7 patients. Overall, complete or near-complete occlusion was achieved in 43 patients (89.6%) after the final embolization. Patients with mural channels received the most embolization sessions (1.4 sessions per patient). Procedural venous drainage-related complications occurred in patients with multiple shunt types including mural channel shunts (n = 3). All bridging vein shunts were completely occluded during a single transarterial embolization session.

CONCLUSION

The 4 shunt patterns of DAVFs demonstrate distinct characteristics for the fistula, sinus and cortical vein connection. Meticulous analysis of the angioarchitectural characteristics and clinical implications is warranted for safe and effective treatment.

Endovascular Management of Intracranial Dural Arteriovenous Fistulas: Transarterial Approach

In this second of 3 review articles on the endovascular management of intracranial dural AVFs, we discuss transarterial treatment approaches. The treatment goal is to occlude the fistulous point, including the most distal portion of the arterial supply together with the most proximal portion of the draining vein (ie, the "foot" of the vein), which can be accomplished with liquid embolic agents via transarterial access. Anatomic factors to consider when assessing the safety and efficacy of a transarterial approach using liquid embolic agents include location, angioarchitecture, and proximity of arterial feeders to both the vasa nervosum of adjacent cranial nerves and the external carotid-internal carotid/vertebral artery anastomoses. Anatomic locations typically favorable for transarterial approaches include but are not limited to the transverse/sigmoid sinus, cerebral convexity, and superior sagittal sinus. In this review article, we discuss the technical approaches, outcomes, potential complications, and complication avoidance strategies for transarterial embolization.

Giant dural arteriovenous fistula in an infant

Dural arteriovenous fistulas (dAVFs) are commonly encountered by the neurosurgeon. Herein, we present a case illustration of an infant presenting with an extremely large fistula that took up a significant part of the intracranial volume. A one-month-old female presented with irritability and failure to thrive. She was the product of a 35-week pregnancy and was delivered vaginally without complications or a difficult labor. Based on the findings of magnetic resonance imaging, the diagnosis of a giant dAVF involving the transerve-sigmoid sinuses was made. The patient was scheduled for an arteriogram but died before the procedure could be performed. Such a case illustrates how large some dAVF can become and at a very early age. As in the present case, the patient was minimally symptomatic. Therefore, the time to intervention after diagnosis is thus, sometimes, critical.

Transarterial embolization of dural arteriovenous fistulas of the lateral sinuses with stent-assisted sinus protection

BACKGROUND

The balloon-assisted sinus protection technique has been described as a sinus-preserving technique during transarterial embolization (TAE) of dural arteriovenous fistulas (DAVFs). However, some serious complications of this technique have been documented.

OBJECTIVE

To describe our preliminary experience with a new technique called stent-assisted sinus protection (SSP).

METHODS

We performed a retrospective analysis of seven consecutive patients with type I or IIa DAVFs of the lateral sinus treated by TAE with a closed-cell stent temporarily deployed in the sinus.

RESULTS

Of the seven patients, four had type I DAVF, and three had type IIa DAVF. The patency of all involved sinuses and their tributaries (including the inferior anastomotic vein and the superior petrosal sinus) was preserved. At the end of the procedure, all stents were successfully retrieved with embolic particles trapped in their meshes. No procedural complications were noted. Clinical follow-up was satisfactory, with complete resolution or significant reduction of pulsatile tinnitus.

CONCLUSIONS

SSP appears to be feasible and probably safe. However, larger studies are needed to confirm these preliminary results.

Balloon-backstop technique: Preserving physiologic venous drainage during transvenous coil embolization of sigmoid sinus dural arteriovenous fistulas

Dural arteriovenous fistulas can lead to catastrophic intracranial hemorrhage if left untreated. Transvenous embolization can cure arteriovenous fistulas, but preserving normal venous structures can be challenging. Inadvertent embolization of a functioning vein can result in catastrophic venous infarction or hemorrhage. Here, we report a case using balloon-assistance to facilitate preservation of the superior petrosal sinus during transvenous embolization of a sigmoid sinus dural arteriovenous fistula.

Utility of targeted balloon protection of the venous sinus for endovascular treatment of dural arteriovenous fistula by transarterial embolization with Onyx: A case report and literature review

Background:

Onyx has already been reported as an effective and safe agent in transarterial embolization of cranial dural arteriovenous fistula (d-AVF). However, successful treatment is related to not only complete shunt obliteration but also preservation of a normal route of venous drainage. Here, we present a case of transverse sigmoid d-AVF in which successful treatment was achieved by transarterial Onyx embolization with targeted balloon protection of the venous drainage.

Case Description:

A 70-year-old man presented with a 3-month history of tinnitus in the left ear and mild headache. Magnetic resonance imaging (MRI) showed a cluster of abnormal blood vessels in the area of the left transverse sinus (TS)-sigmoid sinus (SS) junction. Cerebral angiography demonstrated a Cognard type IIa d-AVF at the left TS-SS junction, supplied mainly by vessels such as the left middle meningeal artery, left occipital artery, and left meningohypophyseal trunk. In the venous phase, the ipsilateral TS-SS was recognized as a functional sinus and the left vein of Labbe drained into the TS near the drainage channel. Based on these findings, we decided to perform endovascular treatment under a transarterial approach with Onyx using targeted balloon protection of the venous sinus to protect against Onyx migration and preserve antegrade sinus flow. The patient recovered well without sequelae, and follow-up MRI 12 months later showed complete disappearance of the d-AVF.

Conclusion:

This treatment strategy using targeted balloon protection may be very useful to preserve antegrade sinus flow in patients with Cognard type IIa d-AVF.

Target Coil Embolization Using the Combined Transarterial and Transvenous Balloon-assisted Technique for Traumatic Direct Carotid Cavernous Fistula

Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Cerebral angiography revealed a shunt from the internal carotid artery (ICA) to the cavernous sinus (CS), which indicated DCCF. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique was performed. Angiography was performed 1 week after surgery to confirm the disappearance of DCCF. No recurrence was observed during the 1-year follow-up after treatment. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique is safe and effective for the treatment of traumatic DCCF.

Central nervous system vascular malformations: A clinical review

CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range spans lesions with a risk of devastating neurological compromise to lesions with a slow, static or benign course. Advances in neurovascular imaging along with increased utilization of these advances, have resulted in more frequent identification of these lesions. In this article, we provide an overview on definitions and classifications of CNS vascular malformations and outline the etiologic, diagnostic, prognostic, and therapeutic features for each entity. This review covers intracranial and spinal cord vascular malformations and discusses syndromes associated with CNS vascular malformations.

Endovascular Treatment for Dural Arteriovenous Fistulae Using a Sinus Protection Balloon to Maintain the Patency of the Dural Sinus

We introduce our technique to treat dural arteriovenous fistulae (dAVFe) under sinus balloon protection. The Kaneka Shoryu 7 × 7 mm balloon was used for sinus occlusion. Initially, the balloon was inflated slowly using 1.5-2.0 mL of saline on the table. A 6F guiding catheter was navigated into the proximal portion of the lesion from the jugular vein of the affected side. The balloon catheter was introduced to the point occluding the shunt. The balloon was temporarily inflated to determine the occlusion point without occluding the outlet of the vein of Labbe. ONYX injection was started from the microcatheter located at just proximal to the shunt point under sinus balloon occlusion. ONYX penetrated the feeding arteries in an antegrade and retrograde manner. After the penetration of ONYX into each feeding artery, the inflated balloon was temporarily deflated to examine the residual shunt. If a small shunt remained, the balloon was inflated again and ONYX injection was continued. To cure dAVF, the location of the balloon is important. The guiding catheter should be placed just proximal to the shunt and the balloon catheter should be gently pulled to stabilize the balloon position.

Long-term follow-up of transarterial balloon-assisted Onyx embolization for endovascular treatment of dural arteriovenous fistulas: A single-institution case series and literature review

OBJECTIVE

Dural arteriovenous fistulas (DAVFs)-specifically, symptomatic DAVFs with cortical venous reflux-are aggressive lesions with a poor prognosis. Intra-arterial endovascular closure is considered the optional treatment for DAVFs and is currently performed at several international centers. However, long-term outcomes remain unknown. This study investigated the long-term efficacy and safety of transarterial balloon-assisted Onyx embolization in the treatment of DAVFs.

METHODS

A total of 14 consecutive patients who underwent endovascular treatment for DAVFs were treated by balloon-assisted Onyx embolization. Additionally, we retrospectively reviewed all cases reported in the literature and compared the outcomes of patients treated with single- vs dual-lumen microcatheters.

RESULTS

The patients at our institution were followed-up for 114.57 ± 33.52 months. Embolization was performed by balloon-assisted Onyx injection via a single feeding artery. Complete occlusion was achieved in 13 cases and partial occlusion in 1 case. At the final follow-up, all patients were functionally independent (Modified Rankin Scale score of 0-2), with no recurrence. In our review of 70 published cases of DAVFs that underwent endovascular treatment by balloon-assisted Onyx embolization, single- and dual-lumen balloon catheters were used in 33 and 37 patients, respectively. In the former group, there was complete or near-complete occlusion in 32 cases and partial occlusion in 1 case; and in the latter, there was complete or near-complete occlusion in 35 cases and partial occlusion in 2 cases. There were no deaths following endovascular treatment.

CONCLUSION

Measurable and durable outcomes can be achieved by endovascular treatment of DAVFs with the transarterial balloon-assisted Onyx embolization technique, especially in cases with small, distal, and circuitous feeding arteries.

Transarterial Treatment of Cranial Dural Arteriovenous Fistulas: The Role of Transarterial and Transvenous Balloon-Assisted Embolization

BACKGROUND AND PURPOSE

Treatment of dural arteriovenous fistulas can be performed by transarterial or transvenous accesses. For those fistulas located at a dural sinus wall, obliteration of the sinus might lead to a substantial risk of complications if the occluded sinus impairs normal venous drainage. For those fistulas with direct leptomeningeal venous drainage, navigation to reach the arteriovenous shunting point of a leptomeningeal vein is usually technically demanding. We report the outcomes of patients with dural AVFs treated by transarterial injection of liquid embolic agents assisted by transarterial double-lumen balloon catheters and/or transvenous balloon catheters.

MATERIALS AND METHODS

This was a retrospective, 3-center study including patients with dural AVFs treated with a balloon-assisted technique in at least 1 treatment session. Angiographic follow-up was performed at 6 months. Clinical assessment was performed at admission and discharge and was reassessed at 30-day and 6-month follow-ups.

RESULTS

Forty-one patients with 43 dural AVFs were treated. Thirty-four fistulas were located at a dural sinus wall. Treatment was performed using only a transarterial approach in 42 fistulas. Only 1 session was needed for complete obliteration of the fistula in 86% of the patients. Immediate complete angiographic occlusion was achieved in 39 fistulas. Of the 41 controlled fistulas, 40 (97.6%) were completely occluded at 6 months. Thirty-nine fistulas (95.1%) were cured without any report of major neurologic events or death during follow-up.

CONCLUSIONS

Transarterial balloon-assisted treatment of dural AVFs with or without transvenous balloon protection was shown to be safe and effective.

Results of 1940 embolizations for dural arteriovenous fistulas: Japanese Registry of Neuroendovascular Therapy (JR-NET3)

OBJECTIVE

Embolization is the most common treatment for dural arteriovenous fistulas (dAVFs). A retrospective, multicenter observational study was conducted in Japan to clarify the nature, frequency, and risk factors for complications of dAVF embolization.

METHODS

Patient data were derived from the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET3). A total of 40,169 procedures were registered in JR-NET3, including 2121 procedures (5.28%) in which dAVFs were treated with embolization. After data extraction, the authors analyzed complication details and risk factors in 1940 procedures performed in 1458 patients with cranial dAVFs treated with successful or attempted embolization.

RESULTS

Transarterial embolization (TAE) alone was performed in 858 cases (44%), and transvenous embolization (TVE) alone was performed in 910 cases (47%). Both TAE and TVE were performed in one session in 172 cases (9%). Complications occurred in 149 cases (7.7%). Thirty-day morbidity and mortality occurred in 55 cases (2.8%) and 16 cases (0.8%), respectively. Non-sinus-type locations, radical embolization as the strategy, procedure done at a hospital that performed dAVF embolization in fewer than 10 cases during the study period, and emergency procedures were independent risk factors for overall complications.

CONCLUSIONS

Complication rates of dAVF embolization in Japan were acceptable. For better results, the risk factors identified in this study should be considered in treatment decisions.

First clinical multicenter experience with the new Scepter Mini microballoon catheter

BACKGROUND

Balloon-assisted techniques can improve the endovascular treatment of cerebrospinal vascular malformations. The aim of this study was to report the first clinical multicenter experience with the new Scepter Mini dual-lumen microballoon catheter.

METHODS

Patients with cerebral or spinal vascular malformations treated with the Scepter Mini at seven European neurovascular centers were retrospectively reviewed. Clinical data, angiographic features of the vascular malformations, procedural parameters including the type of application, navigability, technical failures, complications and embolization success were assessed.

RESULTS

The usage of 34 Scepter Mini microballoon catheters in 20 patients was analyzed. Most treated malformations (80.0%) were cerebral arteriovenous malformations. Four different applications were reported: embolization via Scepter Mini (n=23, 67.6%), balloon-occlusion with simultaneous embolization via a second microcatheter (n=3, 8.8%), diagnostic angiography with simultaneous balloon-inflation for flow arrest (n=4, 11.8%), and navigation support (n=4, 11.8%). The mean diameter of the blood vessels in which the Scepter Mini was inflated was 1.9±0.5 mm. The navigability of the Scepter Mini was rated as 'easy' or 'very easy' in 88.2% of cases. Complete occlusion of the malformation was achieved in 60.9% of cases. Technical failures occurred in 4/23 embolization procedures, and all were related to insufficient stability of the balloon within the vessel. No complications related to the Scepter Mini were observed, while unrelated complications occurred in three patients (15.0%).

CONCLUSIONS

The Scepter Mini is a promising new device for balloon-assisted embolization of cerebrospinal vascular malformations via small feeders. Beyond embolization, the Scepter Mini can also be used for other applications, such as superselective flow arrest and navigation support.

Balloon-assisted Onyx Embolization in the Management of Complicated Dural Arterioevenous Fistula

Objective

Dural arteriovenous fistula (dAVF) is an abnormal vascular communication between the meningeal artery and vein at the dura mater, with frequent recruitment of collateral arterial pedicles. In recent years, Onyx embolization has become the mainstay intervention for dAVF at various locations, although an unfavorable vascular anatomy often limits effective obliteration of the lesion. Balloon assistance may facilitate curable occlusion of the abnormal shunt with Onyx while preserving the patency of the affected sinus, even in complicated dAVFs.

Methods

We retrospectively reviewed the clinical and angiographic findings of patients with dAVF treated endovascularly in our institution between September 2018 and August 2019. Based on the detailed analysis of individual angioarchitecture, we defined complicated dAVF as lesions for which a complete cure is considered difficult to achieve with simple transarterial Onyx embolization alone, primarily due to a high flow and/or diffuse shunt with or without drainage to the functioning but compromised sinus. We evaluated the preoperative symptoms, anatomical classification, endovascular procedure, radiologic results, and clinical outcomes of these patients.

Results

Five patients met our criteria, all of whom were treated with balloon-assisted Onyx embolization (two superior sagittal sinus dAVF, two transverse-sigmoid sinus dAVF, and one torcular dAVF). In four cases, Onyx was injected from a tiny branch of the middle meningeal artery under balloon occlusion of the collateral arteries or balloon devascularization of the competitive inflow. In three cases, balloon sinus protection was performed to prevent the inadvertent occlusion of the vital venous outflow with Onyx. In one case, for the complementary occlusion of the remnant shunt through the previously coiled but recanalized occipital artery, Onyx was injected from the wire lumen of a dual-lumen balloon catheter to avoid undesirable reflux. The angiographic results were an anatomical cure in four cases and near-complete occlusion in one case. No procedural complications were observed in any cases. The clinical outcome was a complete cure in four cases and improvement in one case.

Conclusion

Our cases suggest that balloon devascularization can improve the unfavorable flow environment and simplify the vascular anatomy. Balloon sinus protection can support not only securing the patency of the normal venous outflow but also encourage aggressive intervention. Onyx injection via a dual-lumen balloon catheter can augment the controllability of embolization while preventing reflux. Each of these techniques can facilitate safe and effective Onyx embolization in the treatment of complicated dAVFs, and their combination may further expand the therapeutic horizon.

Neuroendovascular surgery

Neuroendovascular surgery and interventional neuroradiology both describe the catheter-based (most often) endovascular diagnosis and treatment of vascular lesions affecting the brain and spinal cord. This article traces the evolution of these techniques and their current role as the dominant and frequently standard approach for many of these conditions. The article also discusses the important changes that have been brought to bear on open cerebrovascular neurosurgery by neuroendovascular surgery and their effects on resident and fellow training and describes new concepts for clinical care.

Factors Predicting De Novo Formation of Fistulas After Dural Fistula Embolization Using Venous Sinus Balloon Protection

BACKGROUND

Endovascular embolization with transvenous sinus preservation using balloon is at present the preferred modality for dural arteriovenous fistulas involving venous sinuses (sagittal, transverse, and sigmoid) with potential drainage function. The aim of the study was to evaluate the necessity and medium-term efficacy of this technique.

METHODS

Patients with dural arteriovenous fistulas involving large sinuses who underwent vascular embolization with transvenous balloon protection technique at our center from December 2012 to July 2017 were retrospectively reviewed. The clinical symptoms, postoperative and mid-term follow-up imaging results, perioperative complications, and follow-up clinical outcomes were analyzed.

RESULTS

Eighteen patients (8 women and 10 men) with mean age 49 years were included in this study. Complete (16 of 18) or near-complete (1 of 18) occlusion of original fistula was achieved in 17 patients (94.4%). Recurrence of original fistula (1 of 18) or de novo fistula (3 of 18) occurred in 4 patients (22.2%). The patency rate of balloon-protected sinus was 72.2% (13 of 18) during the follow-up, and the involved sinuses were eventually occluded in 5 patients (27.8%). The frequency of de novo fistulas was higher in patients with sinus occlusion (P < 0.05). Stenosis of the involved sinus was more likely related to balloon-protected sinus occlusion (P < 0.05). After a mean follow-up of 17.6 months, 17 patients (94.4%) achieved remission of the original symptoms.

CONCLUSIONS

Transvenous balloon protection technique maintains sinus patency in most cases, and preoperative stenosis increases the probability of sinus occlusion. De novo fistula is related to sinus occlusion during the follow-up.

The Influence of Angioarchitectural Features on the Success of Endovascular Embolization of Cranial Dural Arteriovenous Fistulas with Onyx

BACKGROUND AND PURPOSE

Endovascular embolization can be an effective treatment for cranial dural arteriovenous fistulas. However, a considerable number of dural arteriovenous fistulas still cannot be treated sufficiently. The purpose of this study was to report our single-center experience of endovascular embolization of dural arteriovenous fistulas with Onyx, including the investigation of the influence of angioarchitectural features on the treatment success.

MATERIALS AND METHODS

Clinical data, angioarchitectural features, complications, treatment success (defined as complete symptom remission for low-grade dural arteriovenous fistulas and complete occlusion for high-grade dural arteriovenous fistulas), and occlusion rates were assessed. The influence of various angioarchitectural features (including location, pattern of venous drainage, and quantity and origin of feeding arteries) was investigated using multivariable backward logistic regression.

RESULTS

One hundred four patients with 110 dural arteriovenous fistulas were treated in 132 treatment procedures. Treatment success and complete occlusion rates were 81.8% and 90.9%, respectively. After a mean follow-up of 23.6 months, 95.5% of the patients showed complete symptom remission or symptom relief. The overall complication rate was 8.3% (4.5% asymptomatic, 2.3% transient, and 1.5% permanent complications). Logistic regression showed that ≥10 feeding arteries (P = .041) and involvement of the ascending pharyngeal artery (P = .039) significantly lowered the probability of treatment success. Treatment success tended to be lower for low-grade dural arteriovenous fistulas, Cognard type I dural arteriovenous fistulas, and dural arteriovenous fistulas with involvement of dural branches of the internal carotid artery, however without reaching statistical significance in the multivariable model.

CONCLUSIONS

The presence of multiple feeding arteries and involvement of the pharyngeal artery negatively influence the treatment success of endovascular embolization of cranial dural arteriovenous fistulas with Onyx.

The variant with the absence of the superior petrosal venous and sinus: A potential pitfall of transvenous balloon-assisted embolisation of Borden type II transverse-sigmoid dural arteriovenous fistula

We describe a patient with Borden type II transverse-sigmoid dural arteriovenous fistula. On the venous phase of the left vertebral artery injection, there was no superior petrosal veins and sinus on the side of lesion. After transvenous balloon-assisted Onyx embolisation, the patient developed extensive venous infarction from venous occlusion. This report calls attention to a highly unusual variant in which the superior petrosal veins and sinus are absent, and the cerebellar veins will be drained by tributaries of the bridging veins in this circumstance. In such circumstances, occlusion of the bridging vein on the tentorial cerebellar surface may lead to complications during transverse-sigmoid dural arteriovenous fistula embolisation.

The Application of Copernic RC Balloon in Endovascular Treatment of Complex Intracranial Dural Arteriovenous Fistula of the Transverse Sigmoid Sinus

BACKGROUND

During endovascular treatment of complex intracranial dural arteriovenous fistulas (DAVFs) of the transverse sigmoid sinus, it can be difficult to preserve the patency of the dural sinus. We have described the details of the transvenous balloon-assisted technique using Copernic RC balloon as a treatment option for patients with complex DAVFs of the transverse sigmoid sinus.

CASE DESCRIPTION

In these 2 cases, the Copernic RC balloon was navigated into the internal jugular vein and placed at the distal end of the DAVFs in the transverse sinus. After the balloon was fully inflated, a transarterial glue embolization or transvenous Onyx tunnel technique was performed, with complete exclusion of the fistula and patency of the transverse sigmoid sinus. No immediate or delayed postoperative complications occurred.

CONCLUSION

Transvenous Copernic RC balloon-assisted embolization of DAVFs in the transverse and sigmoid sinuses is safe and can offer complete occlusion of DAVFs and remission of clinical symptoms.

Perspective review on applications of optics in cerebral endovascular neurosurgery

Cerebral endovascular neurosurgery has transformed the way we manage cerebrovascular disease. Several landmark trials have demonstrated the effectiveness of endovascular techniques leading to continued technological development and applications for various diseases. The utilization of optical technologies and devices is already underway in the field of endovascular neurosurgery. We discuss the contemporary paradigms, challenges, and current optical applications for the most common cerebrovascular diseases: carotid atherosclerotic disease, cerebral aneurysms, intracranial atherosclerosis, and dural arteriovenous fistulas. We also describe needs-based opportunities for future optical applications, with the goal of providing researchers a sense of where we feel optical technologies could impact the way we manage cerebral disease.

Endovascular treatment of dural arteriovenous fistulas with sinus drainage: Do we really need to protect the sinus?

BACKGROUND AND PURPOSE

Dural arteriovenous fistulas (DAVFs) with direct antegrade sinus drainage have a benign natural history but bruit can be disabling. Disconnection of the draining sinus is considered curative. We present the treatment results of 14 patients with a dural arteriovenous fistula with antegrade sinus return with emphasis on functionality of the involved sinus and the need for sinus patency.

MATERIALS AND METHODS

Between January 2009 and January 2018, 14 patients with a DAVF with direct antegrade sinus drainage were treated in our institution. There were two men and 12 women (1: 6) with a mean age of 61 years (median 61, range 43-78). Clinical presentation was unbearable pulsatile bruit in all cases. Thirteen were draining in the sigmoid or transverse sinus and one drained into the inferior petrosal sinus.

RESULTS

Twelve of 14 (86%) patients had a draining sinus non-functional for the brain. In ten of these 12 patients the sinus was occluded with liquid embolic or coils. In the two patients with a functional sinus, the fistula was successfully occluded without occluding the sinus. One patient with inferior petrosal sinus drainage required transvenous embolization. There were no permanent adverse events of treatment.

CONCLUSIONS

Patients with DAVFs with direct antegrade sinus drainage were cured using a strategy of endovascular transarterial and transvenous embolization. Most patients had a non-functional sinus that could be occluded for cure.

Current status of endovascular treatment for dural arteriovenous fistula of the transverse-sigmoid sinus: A literature review

Most intracranial dural arteriovenous fistulae (DAVFs) involve the transverse-sigmoid sinus (TSS), and various types of endovascular treatment (EVT) have been involved in managing TSS DAVFs. A current, comprehensive review of the EVT of TSS DAVFs is lacking. This study used the PubMed database to perform a literature review on TSS DAVFs to increase the current understanding of this condition. For high-grade TSS DAVFs such as Borden type 3, the goal of EVT is curative treatment. However, for low-grade TSS DAVFs such as Borden type 1 and some Borden type 2 TSS DAVFs, symptom relief or elimination of cortical reflux may be sufficient. Currently, EVT has become the first-line treatment for TSS DAVFs, including transarterial embolization (TAE), transvenous embolization (TVE) or both. TAE alone and TSS balloon-assisted TAE are also commonly used. However, TVE for TSS DAVFs is recognized as the most effective treatment, including coil direct packing TSS, Onyx® (ethylene vinyl alcohol copolymer) TVE, and balloon-assisted Onyx® TVE, which are commonly applied. In addition, TSS reconstructive treatment can be an effective procedure to treat TSS DAVFs. EVT is accompanied with complications, including technique- and treatment-related complications. Although complications may occur, TSS DAVFs have an acceptable prognosis after EVT.

Endovascular Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Fistulas: A Single-Center Experience with Long-Term Follow-Up

BACKGROUND

Endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TSDAVFs) remains challenging because of their complex anatomic factors. The aim of our study was to evaluate the long-term efficacy and safety of endovascular treatment of TSDAVFs.

METHODS

From January 2008 to December 2014, 44 patients with TSDAVFs were treated endovascularly at our institution. The clinical and angiographic data were retrospectively collected, and the occlusion rate, complications, and clinical outcomes were analyzed.

RESULTS

Overall, 44 patients (26 males and 18 females) were identified, with a mean age of 47 years (range, 13-68 years). Of the 44 patients, 5 presented with Cognard type I fistula, 12 with type IIa, 6 with type IIb, 13 with type IIa+IIb, 2 with type III, and 6 with type IV. Complete (n = 29) or near-complete (n = 7) occlusion of the fistula was achieved in 36 patients (82%). Two patients experienced a transient neurological deficit (cranial nerve VII). In 31 patients with angiographic follow-up (range, 2-40 months) data available, the occlusion remained in 25, 2 previously minimal residual fistulas were completely occluded, 3 residual fistulas were unchanged, and 1 fistula recurred. Two patients with cortical venous reflux who had received incomplete treatment died of intracranial hemorrhage during the follow-up period. Of the 37 patients with clinical follow-up (mean, 33.6 months) data available, clinical cure was achieved in 29, residual symptoms remained unchanged in 7, and symptoms had deteriorated in 1.

CONCLUSIONS

Favorable and durable outcomes were achieved with endovascular treatment of TSDAVFs. TSDAVFs with cortical venous reflux carry a high risk of hemorrhage and require curative treatment.

Endovascular Treatment of Dural Arteriovenous Fistulas Using Transarterial Liquid Embolization in Combination with Transvenous Balloon-Assisted Protection of the Venous Sinus

BACKGROUND AND PURPOSE

Sinus-preserving endovascular embolization was described as a promising treatment technique for dural arteriovenous fistulas. Our aim was to report our single-center experience in patients with dural arteriovenous fistulas who were treated with transarterial liquid embolization in combination with transvenous balloon-assisted protection of the affected venous sinus.

MATERIALS AND METHODS

A retrospective analysis of a prospectively collected data base was performed. Demographic and clinical data, angiographic features of the dural arteriovenous fistulas, procedural parameters, complications, treatment success, follow-up imaging, and clinical outcome were assessed.

RESULTS

Twenty-two patients were treated in 25 procedures. All patients were symptomatic, of whom 81.8% presented with tinnitus; 9.1%, with ocular symptoms; and 9.1%, with headache. Most fistulas were located at the transverse and/or sigmoid sinus. The most frequent fistula type was Cognard IIa+b (40.9%), followed by Cognard I (31.8%) and Cognard IIa (27.3%)/Borden I (59.1%), followed by Borden II (40.9%). The affected sinus could be preserved in all except for 1 patient in whom it was sacrificed in a second treatment procedure by coil embolization. The overall complete occlusion rate was 86.4%. The overall complication rate was 20%, with transient and permanent morbidity and mortality of 8%, 0%, and 0%, respectively. After a mean follow-up of 18 months, most patients (68.2%) achieved complete symptom remission, 27.3% showed symptom relief, and 4.6% had stable symptoms.

CONCLUSIONS

Transarterial liquid embolization of dural arteriovenous fistulas in combination with transvenous balloon-assisted protection of the venous sinus is feasible and safe and offers high rates of occlusion and of symptom remission.

Transarterial Onyx Embolization of Bilateral Transverse-Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist-Initial U.S. Experience with Copernic RC Venous Remodeling Balloon

BACKGROUND

Currently, the mainstay treatment of dural arteriovenous fistula (DAVF) involves endovascular approaches, especially for high-grade lesions. Transarterial embolization with preservation of venous sinuses has become the preferred approach due to the development of newer liquid embolic agents. For further precision during embolization, the use of temporary balloon occlusion to protect the patency of dural sinuses from the embolic agent's migration has been described.

METHODS

A 64-year-old man presented with bilateral pulsatile tinnitus and visual decline. A diagnostic cerebral angiogram demonstrated a complex bilateral Borden type II and Cognard type IIB DAVF. Treatment was carried out endovascularly under general anesthesia in a staged fashion. In the first stage, the balloon was inflated during embolization to protect the right transverse sigmoid venous sinus system and torcula. In the second stage, the balloon was again inflated to protect the left transverse sigmoid venous sinus system and torcula during embolization. Complete obliteration of the left DAVF was achieved, and patency of the left transverse and sigmoid sinuses was preserved. Patency of the right transverse and sigmoid sinus was also conserved post procedure.

RESULTS

The patient was treated successfully with transarterial Onyx embolization with transvenous balloon protection of the sinus.

CONCLUSIONS

This case is the first reported use of the Copernic RC balloon in the United States under the compassionate use guidelines of the U.S. Food and Drug Administration. The use of this balloon is becoming a useful treatment alternative in selected cases of DAVFs as it improves the safety and efficacy of transarterial embolization as evidenced in this case.