Direct Access Embolization of Intracranial Vascular Pathology: Preliminary Experience and Technical Notes

Abstract

Abstract INTRODUCTION Transarterial embolization is widely used for definitive or adjunctive treatment of intracranial vascular pathology and is most commonly performed via the transfemoral approach. However, the ability to treat the lesion successfully depends significantly on the navigation of microcatheters into the distal circulation. Vascular tortuosity oftentimes precludes one's ability to position a microcatheter near the target lesion. In these cases, embolization relies on the ability of the embolysate to travel a fair distance before reaching the target lesion. METHODS We describe our preliminary experience with direct access embolization using a hybrid operating/bi-plane angiography suite. A craniotomy is performed to access and isolate the feeding artery. A microcatheter is inserted into the vessel and navigated to the target lesion. Embolization proceeds using bi-planar angiography. RESULTS Direct access embolization was attempted in 2 patients (45 M, 64 M) during treatment of a dural arteriovenous fistula and an arteriovenous malformation. Three treatments were performed (1 for dAVF, 2 for AVM) using Onyx (Medtronic; Dublin, Ireland) involving 4 vascular pedicles. The dAVF was successfully occluded via this approach. Significant nidal penetration/embolization was achieved in the AVM allowing for complete surgical resection. There were no complications related to this procedure. CONCLUSION Direct access embolization is an innovative technique combining both open and endovascular treatment of intracranial vascular pathology. It can be used in instances where difficult vascular anatomy preclude traditional transarterial routes of navigation. Further investigation is required to better define the safety, efficacy, and best practices of this novel technique.