Complex Dural Arteriovenous Fistula Research Articles

Angioarchitecture and Endovascular Therapy of Infantile Dural Arteriovenous Fistulas.

Infantile dural arteriovenous fistula (IDAVF) is a rare complex dural arteriovenous fistulas. This study is to provide a comprehensive understanding of the angioarchitecture of arteriovenous shunts in IDAVFs and planning endovascular treatment. Five cases of IDAVF and a literature review were analyzed to characterize the shunt patterns of IDAVFs in terms of anatomic relations to the arterial feeder, sinuses, and cortical veins. Treatment characteristics and outcomes were evaluated. A total of 37 cases of IDAVF were identified, including 32 cases from the 15 literature studies and five cases from our center. The patients' age is 11 weeks to 27 years, with an average of 6 ± 7.8 years. Fourteen patients were female, and 23 patients were male. IDAVFs were characterized by multiple high-flow fistulas fed by arterial feeders from six vessels converging to enlarged dural sinuses, most of which were torcular, transverse-sigmoid, or superior sagittal sinuses (94.6%). In 31 cases treated endovascularly, only 9 (29%) IDAVFs resulted in complete occlusion. Clinical outcomes were reported in 28 cases treated endovascularly with a 64.3% of morbidity (mRS ≥ 2) and mortality. There were no differences in complete occlusion rate (25% vs 33.3%, P > 0.999) and death rate (21.4% vs 21.4%, P > 0.999) between transarterial and transvenous approaches. IDAVFs were characterized by multiple high-flow fistulas fed by arterial feeders from six vessels converging to enlarged dural sinuses, most of which were torcular, transverse-sigmoid, or superior sagittal sinuses. Considering these multiple suppliers and high-flow shunts, transarterial or transvenous embolization is still insufficient and unsatisfactory.

Dural arteriovenous fistula may be occluded through recanalization of impaired venous sinuses.

To investigate the effect and safety of recanalization of stenosed or occluded venous sinuses for dural arteriovenous fistulas (DAVFs) and possible mechanism of DAVF formation, patients with DAVF accompanied by venous sinus stenosis or occlusion treated with balloon angioplasty and/or stenting were retrospectively enrolled. The clinical data, treatment outcomes and complications were analyzed. In 7 patients enrolled, the DAVF was Cognard IIa grade in 3 (42.9% or 3/7) and IIa + b in 4 (57.1% or 4/7) patients, including complex DAVFs in 2 (28.6% or 2/7). The angioplasty procedure was successful in all (100%) patients, including complete cure in 3 (42.9% or 3/7) patients with the initial Cognard grade IIa, transformation from Cognard grade IIa + b to I in 2 (28.6% or 2/7) patients, and unchanged Cognard grade IIa + b in 2 (28.6% or 2/7) patients. The symptoms were all improved. At 3-month angiographic follow-up, 5 (71.4% or 5/7) cases were cured, whereas 2 cases still had grade I fistulas but no clinical symptoms. Staged embolization in 2 patients resulted in significant symptom improvement. At the last follow-up of a median 4 years, no clinical symptoms were present in 5 (71.4% or 5/7) patients, intermittent headache in 1 (14.3% or 1/7), and death from trauma in 1 (14.3% or 1/7). In conclusion, endovascular recanalization of occluded or stenosed venous sinuses using balloon angioplasty and stenting is able to induce occlusion of DAVFs and is a safe and efficient treatment approach for DAVFs which are possibly caused by significant pressure increase.

Value of Dual Arterial Access for Improved Angiographic Control for Double-Lumen Arterial Balloon Onyx Embolization of Multifeeder Complex Cranial Dural Arteriovenous Fistulas: A Technical Nuance

Here we describe our experience managing intracranial dural arteriovenous fistulas (DAVFs) via endovascular embolization using a transarterial embolization (TAE) technique with liquid embolic agents. We illustrate the technical nuance of using dual arterial access for angiographic control runs in complex DAVFs supplied by multiple feeders from 2 distinct arterial systems. Retrospective analysis of intracranial DAVF embolization as a single treatment technique at our institution from 2013 to2023. Twenty-three patients with intracranial DAVF who underwent endovascular treatment as their initial treatment were included. All embolizations were approached transarterially with Onyx (n= 19), n-butyl cyanoacrylate (n= 2), or a combination (n= 2). Twenty-two patients (96%) had angiographic evidence of complete fistula obliteration after initial embolization. Six DAVF TAEs were performed with dual arterial access for simultaneous embolic delivery and angiographic control intraoperatively. Two patients recanalized twice postprocedure, 1 of whom was found to have incidental new DAVF at follow-up. Median patient follow-up was 12 months (interquartile range, 6-36 months), with a median modified Rankin Scale score on discharge of 1 and a Glasgow Outcome Scale score at 3 months of5. In this initial series of patients with DAVF managed by endovascular embolization, dual arterial access was feasible, safe, and effective in achieving fistula obliteration. Dual-arterial access conveniently provides simultaneous access for control angiography and embosylate delivery intraoperatively.

Combined venous and arterial access in the arm for treatment of a complex dural arteriovenous fistula: a technical video.

Transvenous access is a necessary tool for numerous cerebrovascular pathologies.Transvenous access in the arm offers several benefits compared with transfemoral access, including patient comfort, the avoidance of transfemoral access complications, and the ability to close both radial arterial access and distal arm venous access with a single transradial compression band.1In this video we describe the indications, technical nuances, benefits, and limitations of transvenous access in the arm.neurintsurg;jnis-2023-020996v1/V1F1V1Video 1- Combined venous and arterial access in the arm for treatment of a complex dural arteriovenous fistulaWe present the case of a young patient who presented with pulsatile tinnitus and was found to have a Cognard type IIa dural arteriovenous fistula near the left transverse sigmoid junction.The patient was treated with transvenous embolization via the distal right basilic vein, and a single radial compression band served to close both the arterial and venous access sites.

Transsinusal embolization of transverse sigmoid sinus dural arteriovenous fistula in a hybrid operating room: A technical note

BackgroundUsing the transverse sinus as a conduit to treat a transverse sigmoid sinus dural arteriovenous fistula is uncommon. This report describes a minimally invasive direct puncture technique for the transverse sinus to treat a complex dural arteriovenous fistula in a hybrid operating room. CaseThe patient was a 64-year-old man with intractable status epilepticus. Digital subtraction angiography demonstrated a right transverse sigmoid sinus dural arteriovenous fistula (Borden type II, Cognard type IIa+b). We performed a transcranial direct puncture because the femoral vein approach was not feasible due to bilateral thrombosed sinuses. Under general anesthesia and park-bench patient positioning, the transverse sinus was exposed and catheterized, and the affected sinus was embolized using microcoils. The fistula was completely obliterated, resolving the status epilepticus. ConclusionsDirect puncture of the transverse sinus can be effective for treating a transverse sigmoid sinus dural arteriovenous fistula. In a hybrid operating room, combined treatments can be performed comfortably and safely in a single session of general anesthesia. This treatment option is a viable alternative when other methods are unsuccessful.

Endovascular Treatment of Intracranial Dural Arteriovenous Fistulas: A German Single-Center Experience

Background and Purpose: Intracranial dural arteriovenous fistulas (DAVFs) are abnormal shunts between dural arteries and dural venous sinus or cortical veins. We report our experience with endovascular therapy of primary complex DAVFs using modern embolic agents. Methods: This is a retrospective analysis of patients with DAVFs treated between 2015 and 2019. Patient demographics and technical aspects including the use of embolic agent, access to the fistula, number of treatments, occlusion rates, and complications were addressed. Angiographic treatment success was defined as complete occlusion (CO) of the DAVF. Results: Fifty patients were treated endovascularly. Median age was 61 years and 66% were men. The most common symptom was pulsatile tinnitus in 17 patients (34%). The most frequent location of the DAVF was the transverse-sigmoid sinus (40%). Thirty-six fistulas (72%) had cortical venous reflux. Nonadhesive and adhesive liquid agents were used in 92% as a single material or in combination. CO was achieved in 48 patients (96%). In 28 individuals (56%), only 1 procedure was necessary. Nonadhesive liquid agents were exclusively used in 14 patients (28%) with CO attained in every case. For CO of tentorial DAVFs, multiple sessions were more often required than at the other locations (55 vs. 14%, p = 0.0051). Among 93 procedures, the overall complication rate was 3%. The procedure-related mortality rate was 0%. Conclusion: Endovascular treatment of intracranial DAVFs is feasible, safe, and effective with high rates of CO. In more than half of the patients, the DAVF was completely occluded after a single procedure. However, in tentorial DAVFs, multiple sessions were more often required.

Angio-architecture of complex cranial dural arteriovenous fistulas: A single centre retrospective review of treatment modalities and outcomes

IntroductionCranial dural arteriovenous fistulas (DAVFs) are rare vascular lesions that often harbour complex angio-architectural features. This subtype of DAVF may require multiple, multimodality, or hybrid treatments. In this paper we aim to identify specific angio-architectural features that are present in complex cranial DAVFs and we report our series with respect to treatment modalities and outcomes. MethodsTwenty-five cranial Borden type II and III cranial DAVFs were treated at our Institution from 2013 to 2017. We classified nine (36%) as complex based on specific angio-architectural features. Treatment strategies were based on fistula location, angiographic features and patient's presenting condition. Phone interviews were used to confirm outcome at 6 and 12 months. ResultsFour patients (45%) presented with acute hydrocephalus, and 3 (33%) with intracranial hemorrhage. Multiple and combined treatment sessions were needed for all complex DAVFs. Five patients required 2 endovascular procedures each. One patient had 2 surgeries. The first line of treatment was endovascular in 6 cases (67%) and surgery in 3 (33%). Two treatment-related (22%) complications occurred. Complete disconnection was achieved in 5 out of 9 patients (55%). Two patients with an incomplete disconnection refused further treatment and were well at last follow up, with a partially treated fistula and persistent CVR. The other 3 patients concluded treatment after the end of our data collection period. At 1 year, 7/9 patients had stable or improved clinical symptoms, and 8/9 patients had GOS of 4 or 5. ConclusionsComplex cranial DAVF often require a multidisciplinary approach and multiple treatment sessions should be expected. Specific angio-architectural features that increase DAVF complexity include multiple arterial feeders, especially transosseous or pial, reflux into multiple cortical veins, sinus occlusion/entrapment, venous aneurysms, segmental stenosis, medial or deep location, and association with the deep venous system.

Technical Trick of Combined Embolization of Inaccessible Dural Arteriovenous Fistula by Endovascular Route Only

Endovascular embolization of dural arteriovenous fistula may not be a feasible approach depending on the location and/or surrounding structures. Combined embolization comprising endovascular embolization by direct puncture of the sinus after small craniotomy under fluoroscopic guidance is a good treatment option for lesions that cannot be treated by endovascular embolization alone. We presented 2 cases of dural arteriovenous fistula that could not be treated by endovascular embolization alone. Treatment included direct puncture of the sinus after small craniotomy to access and completely block the lesion. Combined techniques are required for the management of complex dural arteriovenous fistula. We report a treatment method that can be used for lesions that cannot be treated by endovascular embolization alone along with some technical pitfalls.

Hybrid Operating Room Settings for Treatment of Complex Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (dAVFs) are abnormal direct shunts between the occipital or meningeal artery and a meningeal vein or dural venous sinus. Treatment strategies include endovascular, microsurgical, stereotactic radiosurgical, or combined interventions. With few previous reports focused on dAVF treatment in a hybrid operating room (hOR), the authors reviewed their 6-year experience in this unique setting for these complex fistulas. Patients with complex cerebral dAVFs underwent endovascular and microsurgical treatment in the hOR. In this retrospective review, 8 consecutive patients with cerebral dAVFs (Borden type 2 or higher) underwent endovascular and microsurgical treatment. Demographic characteristics, symptoms related to the dAVF, preoperative angiographic features, preinterventional therapies, intraoperative digital subtraction angiography (iDSA), and postoperative clinical and radiologic findings were reviewed. Of these 8 patients, 5 patients underwent multiple embolizations (up to 3) and hybrid procedures, with no procedure-related complications. After microsurgical resection, iDSA revealed remnants of the fistula, which was then immediately re-resected, in 2 patients. At closing of the hybrid procedure, iDSA revealed no fistula remnants in 7 patients (88%). At mean follow-up examination (58 months), 5 patients (62%) had cure of the dAVF, confirmed by noninvasive angiography. Two patients (25%) experienced a recurrence of the dAVF within 5 months. Our hybrid techniques achieved high rates of dAVF obliteration, with all 8 patients achieving good or excellent outcomes and symptom relief. Angiographic follow-up within 6 months after the hybrid procedure is recommended for all patients even when intraoperative findings do not show remnants.

Trans-Cranial Embolisation of a Complex Transverse Sigmoid Sinus Dural Arteriovenous Fistula by Direct Puncture of the Superior Sagittal Sinus.

This technical note describes a direct puncture of the superior sagittal sinus (SSS) to treat a complex dural arteriovenous fistula (dAVF). A 40-year-old female was admitted having a history of increasing confusion. Computer tomography revealed enlargement of the right superior ophthalmic vein and magnetic resonance imaging demonstrated extensive bilateral hemispheric venous engorgement. Digital subtraction angiography (DSA) demonstrated a high flow dAVF involving the right transverse sinus. There was extensive cortical venous rerouting with venous sinus occlusion at the right transverse and sigmoid junction. Under general anesthesia, the sinus was exposed and catheterized. The angiography catheter was fed over the guide wire into the sinus. The remaining right sigmoid and transverse sinus were obliterated using a combination of microcoils and Onyx®. She made a good postoperative recovery, and a repeat DSA at 30 days postoperatively showed evidence of the meningohypophyseal trunk but complete occlusion of the fistula. A check DSA 2 years later confirmed no evidence of a residual fistula. Our case demonstrates the potential use of the SSS as a novel conduit to treat distant targets.

The Procedure-Related Complications of Transarterial Onyx Embolization of Dural Arteriovenous Fistula Using Transvenous Balloon Protection

Transarterial embolizatioin with transvenous balloon protection has been described as a promising technique for intracranial dural arteriovenous fistula. The aim of our study was to report our preliminary experiences of this technique with regard to its safety and efficacy and to emphasize the procedure-related complications. Fourteen consecutive patients with dural arteriovenous fistula were treated with a transvenous balloon-assisted technique between March 2014 and November 2017. All lesions were embolized with Onyx via a transarterial approach with sinus balloon protection to preserve the patency of the dural sinus. Clinical and angiographic data were retrospectively collected and the occlusion rate, complications, and clinical outcome were analyzed. All 14 patients were symptomatic on admission, mean age was 40.9 years, and 9 (64.3%) of them were men. Thirteen patients had a single fistula at transverse-sigmoid sinus (n= 10) or superior sagittal sinus (n= 3), and another patient had multiple fistulas located at SSS/tentorium. Two patients presented with Cognard type I fistula, 12 with Cognard type II (IIa:6;IIb:1;IIa+ b:5). Complete (8/11) or near-complete (3/11) occlusion was achieved in 11 patients (78.6%). Procedure-related complications occurred in 3 cases, including 1 epidural hemorrhage, 1 cerebellar hemorrhage, and 1 cerebellar infarction. At latest clinical follow-up (mean: 13 months), symptoms were resolved on 6 patients, relieved in 7 patients, and deteriorated in 1 patient. The transvenous balloon protection offers an alternative to treat complex dural arteriovenous fistula, but further investigation are needed to lower related complications.

An Onyx tunnel: reconstructive transvenous balloon-assisted Onyx embolization for dural arteriovenous fistula of the transverse-sigmoid sinus.

Transvenous embolization is an effective method for treating dural arteriovenous fistulas (DAVFs) of the transverse-sigmoid sinus (TSS). However, in cases of complicated DAVFs, it is difficult to preserve the patency of the dural sinus. The authors describe the technical details of a new reconstructive technique using transvenous balloon-assisted Onyx embolization as another treatment option in a patient with an extensive and complex DAVF of the left TSS. A microcatheter and compliant balloon catheter were navigated into the left internal jugular vein and placed at the distal end of the DAVF in the transverse sinus. The microcatheter was placed between the vessel wall of the TSS and the balloon. After the balloon was fully inflated, Onyx-18 was injected at the periphery of the balloon in a slow, controlled, progressive, stepwise manner; the balloon and microcatheter were simultaneously withdrawn toward the sigmoid sinus, with Onyx encompassing the entirety of the complex DAVF. The Onyx refluxed into multiple arterial feeders in a distal-to-proximal step-by-step manner, ultimately resulting in an Onyx tunnel. The final angiography study revealed complete obliteration of the DAVF and patency of the TSS. The Onyx tunnel, or reconstructive transvenous balloon-assisted Onyx embolization technique, may be an effective treatment option for large, complex DAVFs of the TSS. This technique may provide another option to facilitate the complete obliteration of the DAVF while preserving the functional sinus.

Hybrid surgery for complex symptomatic intracranial fistulas: a technical note

Objective: To explore the efficacy of hybrid management of complex symptomatic intracranial fistulas in neurovascular hybrid operating room. Methods: From March 2014 to January 2015, 2 complex dural arteriovenous fistulas and 1 carotid cavernous fistulas were managed by hybrid surgeries in the PLA Rocket Force General Hospital.With first attempts with endovascular treatment failed, all cases were finally managed by hybrid surgery.Dural arteriovenous fistulas were approached via meningeal artery followed craniotomy.The carotid cavernous fistulas were treated by direct puncture into the left cavernous sinus after craniotomy. Results: Post-operative angiography demonstrated complete occlusion for 2 cases and nearly complete occlusion for 1 case.All 3 cases had no complications.On discharge 2 patients presented no symptoms and 1 greatly improved.Within the follow-up (1-33 months), 1 patient had recurrence after 21 months and received re-embolization with complete occlusion. Conclusion: Hybrid surgery is a promising method to manage complex intracranial fistulas.

Direct access to the middle meningeal artery for embolization of complex dural arteriovenous fistula: a hybrid treatment approach

Endovascular embolization has become increasingly favored over microsurgical resection for treatment of complex dural arteriovenous fistulas (DAVFs). However, endovascular treatment can be restricted by tortuous transarterial access and a transvenous...

Abstract No. 322 - Ethanol and coil embolization of complex dural arteriovenous fistula

Abstract No. 322 - Ethanol and coil embolization of complex dural arteriovenous fistula

Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula

Background:Some complex dural arteriovenous fistulas (DAVFs) are lesions that typically have numerous arterial feeders. Surgery, including resection of fistulas or skeletonization of the diseased sinus, is still one of the important treatments for these lesions. However, major blood loss is usually encountered during craniotomy because of abundant arterial feeders from the scalp and transosseous vessels. We present a novel approach for obliteration of the fistulas with less blood loss.Methods:Our first case was a 52-year-old male who suffered from syncope and seizure. Cerebral digital subtraction angiography (DSA) revealed complex DAVFs with numerous arterial feeders from bilateral external carotid arteries (ECAs) and drainage into the superior sagittal sinus with cerebral venous reflux. The second case was a 48-year-old male presenting with chronic headache. His DSA also showed complex DAVFs along the superior sagittal sinus with cerebral venous reflux. In both cases, we performed the surgical procedure to obliterate the pathological fistulas after temporary clamping of bilateral ECAs and noted less blood loss than in the conventional surgery.Results:The follow-up DSA showed successful obliteration of the complex DAVFs on the first case and partial improvement on the second case followed by transarterial embolization (TAE). The symptoms of the both patients were relieved after surgery with good recovery.Conclusion:Temporary clamping of bilateral ECAs can improve the safety and ease the surgical excision for complex DAVFs. By using this technique, neurosurgeons can deal with aggressive DAVFs more confidently and calmly.

A Radiation-Induced Meningioma “Cures” A Complex Dural Arteriovenous Fistula

We report a case of spontaneous thrombosis of an extremely complex dural arteriovenous fistula (DAVF), believed to be previously incurable, after the development of a radiation-induced meningioma resulting from prior attempts to treat the fistula with radiosurgery. A very large DAVF was treated over the course of 3 decades with a combination of partial embolization and stereotactic radiosurgery with no angiographic or clinical treatment response at long-term follow-up. However, with the development of new neurologic symptoms 13 years after radiosurgery, a meningioma was found to have arisen in the previously irradiated field, and surprisingly, the fistula had spontaneously thrombosed. The meningioma was successfully removed. We discuss the unique pathophysiology of the radiation-induced meningioma causing this previously incurable DAVF progressing to obliteration. We also review the natural history of DAVFs, including reported rates of spontaneous occlusion, as well as the success of radiosurgery in their treatment. Finally, the incidence of radiosurgery-induced tumors, particularly meningiomas, is reviewed. The relationship between the spontaneous thrombosis of a DAVF and the radiation-induced meningioma is unique and has not previously been reported.

Complex dural arteriovenous fistula in Bannayan-Riley-Ruvalcaba syndrome

In this paper the authors report the case of a complex dural arteriovenous fistula (dAVF) with high-risk features in a 14-year-old girl with Bannayan-Riley-Ruvalcaba syndrome (BRRS), a phosphatase and tensin homolog-associated syndrome, presenting with signs and symptoms of increased intracranial pressure (ICP) that had previously been attributed to pseudotumor cerebri. This fistula was obliterated following 2 stages of embolization, and the patient experienced immediate symptomatic improvement. At the 2-month follow-up evaluation, the fistula remained angiographically occluded, and her symptoms continue to improve. This is the third reported case of an intracranial dAVF in a patient with BRRS. Because high-risk dAVFs can result in devastating morbidity, early detection with vascular imaging is crucial for patients with BRRS presenting with signs of increased ICP. Goals of treatment should include complete fistula obliteration whenever possible.

Endovascular Treatment of Tentorial Dural Arteriovenous Fistulae

Tentorial dural arteriovenous fistula (DAVF) is a rare vascular disease, which accounts for less than 4% of all cases of intracranial DAVF. Because of the high risk of intracranial hemorrhage, patients with tentorial DAVF need aggressive treatment. Management approaches are still controversial, and endovascular treatment has emerged as an effective alternative. In the current work, we describe our experience with the endovascular approach in the treatment of these deep and complex DAVF of the tentorium. Eight patients were treated between January 2006 and July 2009. Six patients (75%) presented with intracranial hemorrhage related to the DAVF rupture. Four patients (50%) had subarachnoid bleeding and two had intraparenchymal hematoma. Endovascular treatment was performed via the transarterial route alone in five cases (62.5%), by the transvenous approach in two cases (25.0%) and in a combined procedure using both arterial and venous routes in one patient (12.5%). Complete obliteration of the fistula was achieved in all cases. The outcome at 15 months was favorable (modified Rankin scale 0-3) in seven (87.5%) patients. Complete cure of the lesion was confirmed in these cases. This paper reports on the effectiveness of endovascular treatment in tentorial DAVF management. The choice of the venous versus the arterial approach is determined by regarding different anatomical dispositions.

Combined Surgical and Endovascular Approach to a Complex Dural Arteriovenous Fistula Involving the Superior Sagittal Sinus and Torcula

A complex dural arteriovenous fistula (dAVF) may require complex treatment strategies to achieve successful obliteration. We describe a combined open surgical and endovascular approach to a dAVF involving the superior sagittal sinus (SS) and torcula. A 68-year-old male with Factor V Leiden mutation presented with altered mental status from venous hypertension secondary to a complex, high-flow Borden III dAVF with internal carotid and bilateral external carotid artery feeders draining into the SS and torcula. Because the venous channel to the recipient SS at the point of convergence of the AV shunting was not accessible transfemorally due to venous stenosis, a surgical strategy using a midline burrhole for direct catheterization of the SS was devised. A balloon was inflated in the sinus during arterial embolization. This technique was effective in achieving embolization of multiple arterial feeders via a single vessel injection. Covered Atrium iCasts were introduced in a telescoping fashion after angioplasty of the posterior SS-torcular junction in an attempt to functionally occlude further AV shunting. Postembolization angiography revealed greatly diminished AV shunting with improved intracranial transit time and retrograde cortical venous drainage. The patient was maintained on anticoagulation and made a complete recovery following the intervention; however, he subsequently deteriorated acutely, and died on postprocedure day 4. This case illustrates the difficulties associated with treating a complex AVF, describes a temporizing solution, and reports a potential complication from placing a covered stent in the SS.