Endovascular Management of Intracranial Dural AVFs: Transvenous Approach.

K.D Bhatia,H Kortman,J Klostranec,T Krings,W Guest,I Radovanovic,V.M Pereira,T Wälchli,H Lee

doi:10.3174/ajnr.a7300

Abstract

In this third review article on the endovascular management of intracranial dural AVFs, we discuss transvenous embolization approaches. Transvenous embolization is increasingly popular and now the first-line approach for ventral dural AVFs involving the cavernous sinus and hypoglossal canal. In addition, transvenous embolization is increasingly used in lateral epidural dural AVFs in high-risk locations such as the petrous and ethmoid regions. The advantage of transvenous embolization in these locations is the ability to retrogradely embolize the draining vein and fistula while reducing the risk of ischemic cranial neuropathy or brain parenchymal infarction commonly feared from a transarterial approach. By means of coils ± ethylene-vinyl alcohol copolymer, transvenous embolization can achieve angiographic cure rates of 80%-90% in ventral locations. Potential complications include transient cranial neuropathy, neurologic deterioration due to venous outflow obstruction, and perforation while navigating pial veins. Transvenous embolization should be considered when dural AVFs arise in proximity to the vasa nervosum or extracranial-intracranial anastomoses.

Highlights

In a series of anteapproaches to transverse-sigmoid dural AVFs (dAVFs) are progressively being replaced by reconstructive transarterial embolization (TAE) approaches with venous sinus balloon protection.[21,22] rior condylar dAVFs, Transvenous embolization (TVE) with coils resulted in a cure in 9 of 14 cases.[27]
As our knowledge of the angioarchitecture of transverse-sigmoid ethylenevinyl alcohol copolymer (EVOH) Occlusion dAVFs has evolved, there is increasing awareness of a parasinus or EVOH is increasingly popular because it can be used to progrescommon arterial collector in the wall of many of these dAVFs that sively occlude the proximal aspect of the draining vein and fistucan be selectively targeted via TVE.[23] lous points in a controlled fashion, resulting in higher rates of significant cortical venous reflux, classified as Borden type III.[36]
Because the microcatheter glue mass and detachable-tip microcatheter are placed in the draincan be advanced into the constrained space of the cavernous ing vein, allowing flow reversal in the vein, with retrograde transsinus and the goal of treatment in this situation is occlusion of mission of EVOH to reach the fistulous point.[41] the sinus, indirect Carotid-cavernous fistulas (CCFs) are an ideal indication for EVOH

Summary

Introduction

Successful obliteration rate for indirect CCFs using TVE with dAVFs, 64% required additional TAE procedures following TVE coil occlusion.[20] In addition, this approach may not be feasible in patients with a contralateral hypoplastic sinus.

Results

Conclusion