Direct Puncture Research Articles

Preoperative Direct Puncture Embolization of Castleman Disease of the Parotid Gland: A Case Report

Background: Castleman disease (CD) is an uncommon benign lymphoproliferative disease characterized by hypervascular lymphoid hyperplasia. We present a unique case of unicentric CD of the parotid gland treated by preoperative direct puncture embolization. Case presentation: A 27-year-old female patient was admitted for a right neck mass. Ultrasound examination and MRI scan documented a hypervascular mass within the right parotid gland. Preoperative embolization was performed by direct puncture technique: a needle was inserted into the core of the mass under both ultrasound and fluoroscopic guidance and SQUID 12 was injected into the mass under fluoroscopic control, achieving a total devascularization. Conclusion: Preoperative direct puncture embolization was safe and effective and provides excellent hemostatic control during the surgical operation, limiting the amount of intraoperative bleeding.

Early Results of the Sandwich Technique Using Cyanoacrylate Glue and Polidocanol Foam Sclerotherapy for the Treatment of Varicose Veins

Background: This is a retrospective analysis of the results of treatment for varicose veins using the sandwich technique with cyanoacrylate glue and foam sclerotherapy. This novel method allows for a substantial reduction in the amount of glue needed for vein closure, and minimizes the risk of granuloma formation and allergic reaction related to the epifascial administration of cyanoacrylate. Methods: This technique was used in 60 patients, 77 intrafascial veins were managed. Vein closures were performed with Venex cyanoacrylate glue and 1–3% polidocanol foam. All procedures were performed under ultrasonographic control, through direct percutaneous punctures of target veins. Follow-ups were scheduled 1–3 weeks after the procedure. If revealed, unclosed segments of the target veins were obliterated at these follow-up visits, with glue and/or sclerotherapy. Results: There were no serious adverse events intra- or postprocedurally. The technical success rate was 100%. The primary success rate at 1–3 weeks follow-up was 84.4%. The primary assisted success rate, after additional closures, was 100%. Conclusions: We demonstrated that the treatment for varicose veins, using a sandwich technique, which combines cyanoacrylate glue and foam sclerotherapy, can be safe and efficient.

Direct superior sagittal sinus puncture via a surgical burr hole for curative embolization of the complex transverse-sigmoid sinus dural arteriovenous fistula: How I do it.

Transvenous embolization of high-grade dural arteriovenous fistulas (dAVFs) is challenging particularly when the direct sinus access is favorable due to the complex venous anatomy which prohibits endovascular access via the transfemoral approach. The procedure was conducted in the hybrid operating suite, where a burr hole was performed, followed by direct catheterization of the superior sagittal sinus. Coil embolization was then executed to achieve complete obliteration of the fistula. The direct puncture of the superior sagittal sinus is a safe and effective method for treating complex dAVFs. This approach grants access to the fistula channel which facilitates curative embolization.

Intraorbital Arteriovenous Fistulas: Case Series and Systematic Review.

Intraorbital arteriovenous fistulas (AVFs) are an extremely rare subtype of intracranial fistula with ophthalmic symptoms similar to cavernous sinus dural AVFs or carotid cavernous fistulas but worse visual outcomes. Here, we present a case series and thorough systematic review on intraorbital AVFs to demonstrate treatment modalities and address this rare type of AVF. We conducted a retrospective study at a single center, in which we identified all cases of intraorbital AVFs that occurred between 2002 and 2022. We collected and analyzed data on demographics, fistula characteristics, treatment methods, clinical outcomes, and fistula closure. In addition, we conducted a systematic review of intraorbital AVFs. Seven cases in our center and 41 cases of intraorbital AVFs reported in the 35 articles were identified. At our center, transarterial embolization (TAE) (42.9%) alone resulted in immediate complete occlusion in 3 cases. Transvenous embolization (14.3%) resulted in one case of immediate complete occlusion. In 2 cases, surgery (28.6%) resulted in immediate complete occlusion. In one case, conservative treatment (14.3%) was used, and the fistula was eventually spontaneously occluded. Immediate complete occlusion rate was 85.7%. One blindness occurred (14.3%). In the literature reported, 3 cases (60%) of retinal artery occlusion were reported when performing TAE via the ophthalmic artery. Two fistulas recurred as reported. In 33 (80.5%) patients, the fistula was finally completely occluded. TAE via the ophthalmic artery carries a high risk of blindness and a low cure rate. Transvenous techniques such as conventional transvenous routes, surgical exposure, or direct puncture of the drainage vein have been used as the first line of treatment for intraorbital AVFs.

Endovascular treatment for sphenoidal region dural arteriovenous fistula.

Sphenoidal region dural arteriovenous fistulas (DAVFs) are rare. Endovascular treatment (EVT) is an effective treatment approach. However, understanding and performing EVT for sphenoidal region DAVFs are difficult and challenging. Therefore, we performed a review to explore this issue further. In this review, we discuss the dural feeders and venous structures of the sphenoidal region, the angioarchitecture of sphenoidal region DAVFs, the role and principle of EVT, various EVT techniques, and the prognosis and complications associated with EVT. We found that various EVT techniques, including transarterial embolization (TAE), retrograde transvenous embolization (TVE), and direct puncture EVT, can be used to treat sphenoidal region DAVFs. TAE represents the most commonly utilized approach. TVE and direct puncture EVT should be limited to highly selective cases. EVT must penetrate the fistula and very proximal venous recipient pouch with a liquid embolic agent or coil the fistula point to have a complete curative effect. Successful EVT can lead to the obliteration of sphenoidal region DAVFs and a good clinical outcome. However, these complications cannot be neglected.

Trans-apical catheter ablation of ventricular tachycardia in a patient with metallic aortic and mitral valves

We present a patient with a history of heart failure and metallic aortic and mitral valves surgeries, who required ablation for a drug-refractory left ventricular tachycardia. But the metallic valves prohibited the insertion of catheters via retrograde or via trans-septal approaches. Therefore, we decided to perform catheter ablation by direct left ventricle puncture through a minithoracotomy. The arrhythmia was successfully ablated via of trans-apical approach and did not recur at six months follow-up.

Pseudoaneurysms embolization with glue via percutaneous direct puncture: a multicenter experience on 54 patients

BackgroundThis retrospective multicentric study aims to report on technical safety and effectiveness of pseudoaneurysms embolization with glue (N-butyl cyanoacrylate) adopting a percutaneous direct puncture approach.ResultsFifty-four patients data were collected from five centers.All patients at the time of treatment presented with unruptured PAs and were hemodynamically stable.True aneurysms and lesions treated with embolics other than glue were excluded.Pseudoaneurysms diagnosis was based on CT and anamnestic data; initial investigation with digital-subtracted arteriography was acquired in all cases; then, percutaneous embolizations were performed in the angio-suite (ultrasound, fluoroscopy, ConeBeam CT guidance) or in CT.Technical success was considered as complete pseudoaneurysm embolization at final imaging with sole percutaneous strategy, without need for additional endovascular embolization.Clinical success was intended as pseudoaneurysm resolution within one week follow-up with stabilization or restored clinical conditions.Pseudoaneurysms origins were traumatic (57.4%), inflammatory (24.1%) or spontaneous (18.5%); 39 patients (72.2%) were symptomatic, presenting with pain and/or pulsatile mass.Mean lesions diameter was 19.3 mm (range: 7–30); pseudoaneurysms were located in abdomen (48.1%), limbs (42.6%) and thorax (9.3%).Coagulation function was impaired in 16.6% and 48.1% was under antiplatelets/anticoagulation therapy.In 16.6% the percutaneous approach followed previous treatments failure.The image-guidance modality for percutaneous puncture was most often ultrasound combined with fluoroscopy (38%).Clinical success was obtained in all patients while technical success occurred in 94.4% because 3 patients required an additional endovascular embolization.Complications were registered in 14.8%, all of low grade without clinical sequelae neither prolonged recovery (7 non target embolizations, 1 post-embolization syndrome).ConclusionsIn this study, pseudoaneurysms embolization with glue via percutaneous direct puncture was safe and effective with a low rate of minor complications.

Direct superficial temporal artery access for middle meningeal artery embolization.

Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.

Pelvic AVM Embolization: A Tricky Affair-Multicenter Retrospective Experience.

Pelvic arteriovenous malformations (pAVMs) are congenital or acquired vascular anomalies, presenting with hematuria, menometrorrhagia, pelvic pain, and varices; they can be life-threatening in case of rupture. Surgical therapies have been proposed but endovascular embolization has been recognized as the primary modality. The aim of this article was to report a retrospective multicenter experience concerning embolization of pelvic AVMs and provide literature overview. We describe 18 patients (14 female and 4 male) diagnosed with pAVM and treated with minimally invasive methods. The pre-procedural imaging evaluation was based on transpelvic and/or transvaginal color Doppler ultrasound, contrast-enhanced computed tomography, and/or magnetic resonance. In 3 cases, the malformation was congenital and in other 15, acquired. Most common symptoms were menometrorrhagia, hematuria, pelvic pain and pressure, and heaviness in the lower abdominal region. In 10 cases (56%), only 1 procedure was required. Eight patients underwent multistage treatment. Complete occlusion of the lesion in post-procedural angiography was observed in 12 patients (67%). No major periprocedural complications were observed. In 14 cases (78%), both satisfactory embolization and significant clinical improvement was achieved in long-term follow-up. Sixteen patients (88%) were at least satisfied with the clinical outcome. One patient reported subsequent successful pregnancy 5 years after the treatment. Hemodynamics of pAVM are variable and thorough understanding of the vessel anatomy is crucial in planning and choosing proper treatment. Both transarterial and percutaneous direct puncture embolization strategies appear safe, technically feasible, and clinically effective. In this manuscript, we discuss the role of interventional radiology methods in the treatment of pelvic arteriovenous malformations along with its advantages, limitations and possible complications. In addition to this, we review the current literature and confront our findings with those made by other authors. We believe that modern endovascular methods offer safe and reliable alternative for traditional surgical therapy and should be therefore considered during multidisciplinary treatment of these patients.

Intraoperative direct venous puncture and embolization for arteriovenous shunt below the conus medullaris: a prospective cohort study

BackgroundArteriovenous shunt below the conus medullaris (AVS-BC) is easily misdiagnosed and mistreated due to its rarity. Achieving an anatomical cure solely through endovascular or surgical means is challenging. This study...

CT-guided lumbar facet cyst rupture and corticosteroid injection: technique, approach, and procedural and clinical success rates.

To evaluate success rates of computed tomography (CT)-guided lumbar facet synovial cyst (LFC) rupture. We retrospectively reviewed all LFC ruptures performed by a single musculoskeletal radiologist with > 10years of experience, using posterior facet approach and/or direct puncture by ipsilateral/contralateral interlaminar, or transforaminal approach. All patients also received a corticosteroid injection. Rupture rates were calculated, and clinical success rate was determined through medical record review. Pre-procedure magnetic resonance imaging (MRI) images and CT procedure images were also reviewed for LFC and facet joint imaging features that may predict rupture. There were 37 patients, 17 (46%) female and 20 (54%) male, ages 62 ± 12 (range 39-87) years. Thirty-four (92%) of LFC were successfully ruptured, 17 (50%) by facet approach and 17 (50%) by direct cyst puncture. At least one direct puncture approach was possible in 35 (95%) patients. No MRI or CT LFC or facet joint features predicted cyst rupture. Thirty-one (91%) of patients reported immediate pain relief, and 19 (53%) did not have further intervention for LFC-related pain. Sixteen (84%) of these patients remained pain-free for an average follow-up time period of 28months. Fourteen (39%) of patients required surgical intervention. There were no complications. Our systematic approach to CT-guided LFC rupture is safe and has high technical and clinical success rates similar to prior studies. Since there are no definitive imaging features that determine rupture success, this procedure can almost always be attempted as a first-line treatment for LFC.

Development of a Direct Non-Puncture Device for Measuring Portal Venous Pressure during Liver Transplantation-A Swine Model.

Portal hypertension-related complications pose a significant risk for liver failure post-transplantation. Thus, accurate monitoring of intraoperative portal venous pressure (PVP) is crucial. However, current PVP monitoring techniques requiring direct percutaneous puncture carry the risk of graft damage. In this study, we present an innovative non-puncture PVP monitoring device (PVPMD) using a 3D-printed prototype. PVPMD design is inspired by the sphygmomanometer principle, and strategically encompasses the portal vein and enables precise PVP measurement through blood flow ultrasonography after temporary occlusion. By a series of mini-pig experiments, the prototype PVPMD demonstrated a strong correlation with invasive catheter measurements in the main trunk of the portal vein (rs = 0.923, p = 0.000). There was a significant repeatability and reproducibility between the prototype PVPMD- and invasive catheter-measured PVP. This indicates that the PVPMD holds immense potential for direct application in liver transplantation and surgery. Moreover, it has the potential to replace catheter-based central venous pressure (CVP) measurements, thereby mitigating catheter-related complications during many surgeries. In conclusion, our innovative device represents a significant advancement in PVP monitoring during liver transplantation, with comprehensive validation from principle exploration to successful animal experiments. We anticipate that this groundbreaking PVPMD will attract the attention of researchers and clinicians, propelling the noninvasive measurement of PVP or other venous/arterial pressures into a new era of clinical practice.

A cavernous sinus dural arteriovenous fistula treated by direct puncture of the superior ophthalmic vein with craniotomy: illustrative case.

The authors report a case of symptomatic cavernous sinus (CS) dural arteriovenous fistula (dAVF) that was successfully treated using direct puncture of the superior ophthalmic vein (SOV) with craniotomy. CS dAVF is commonly treated using transvenous embolization (TVE), with the most common access route via the inferior petrosal sinus (IPS). However, this route is sometimes unavailable because of an occluded, hypoplastic, aplastic, or tortuous IPS. The SOV is an alternative, albeit tortuous and long, route to the CS; therefore, direct SOV puncture is occasionally performed. Direct SOV puncture is mostly percutaneous; however, in this case, it was difficult because of subcutaneous SOV narrowing. As the patient experienced increased intraocular pressure, decreased vision, and eye movement disorders, CS embolization was performed via direct puncture with a craniotomy because of other access difficulties. Several reports have described CS dAVF in patients receiving endovascular treatment via direct SOV puncture using a transorbital approach. However, to the best of the authors' knowledge, this is the first reported case of a CS dAVF treated using TVE with craniotomy. This approach is useful when the SOV cannot be reached intravenously and its distance from the epidermis is long.

Review article: Feasibility of brachiocephalic vein central venous access for the resuscitation of shocked adult trauma patients: A literature review.

Venous access is a key component of managing haemorrhagic shock. Obtaining intravenous access in trauma patients is challenging due to circulatory collapse in shock. This literature review examines the feasibility of direct puncture and cannulation of the brachiocephalic veins (BCVs) for intravenous access in shocked adult trauma patients. Three literature searches were conducted. OVID Medline was searched for articles on the use of the BCVs for venous access in adults and on the BCVs in shock. A third systematic search of OVID Medline, OVID Embase and Cochrane Library was conducted on the use of the BCVs for access in shocked trauma patients. After full-text review, 18 studies were selected for inclusion for the search on the use of the BCVs for access in adults. No studies met the inclusion criteria for the search on the BCVs in shock and BCV access in shocked trauma patients. The BCVs are currently used for central venous access, haemodialysis and totally implantable venous access devices (TIVADs) in adults. There is a preference for the right BCV (RBCV) over the left as the RBCV is more superficial, straighter, larger, has less anatomical variation and avoids the risk of thoracic duct puncture. The BCVs appear to be stabilised in shock by surrounding bony structures. The BCVs may provide a site for initial, rapid access in trauma resuscitation. Further research is required to determine if the BCVs collapse in shock and if venous access using the BCVs is feasible in a trauma resuscitation setting.

Abstract 212: Percutaneous Carotid access in Mechanical Thrombectomy ‐ a safe alternative to transfemoral approach

Introduction Emergent percutaneous carotid artery MER approach for acute ischemic large vessel strokes are rare given the risk of complications and seldom reported. Methods 75‐year‐old left‐handed functional male (mRs:0) with past medical history of HTN, HLD presented to ED after being found on the floor by his family with slurred speech, new onset right sided weakness, with a last known well of 17 hours. NIHSS on arrival was 14 for expressive aphasia, right visual field defect, right facial weakness, significant dysarthria, right hemiparesis, and sensory defect. CT Head demonstrated left MCA territory early ischemic changes. CTA head/neck demonstrated left M1 occlusion with large penumbra. Perfusion data demonstrated no area of core infarct with area of ischemic penumbra in the left MCA territory involving the left frontal, temporal and parietal lobes measuring 161 ml. ASPECT score 5‐6. The patient was deemed a candidate for mechanical endovascular thrombectomy (MER). The procedure was initiated via ultrasound‐guided right common femoral access. After multiple attempts using a wide range of techniques and wire/catheter combinations in order to establish left intracranial access and given extreme angulation/tortuosity/elongation in the proximal left common carotid artery, it was decided to proceed with the catheter position in the left common carotid or the left internal carotid artery that would allow for subsequent catheterization of the intracranial circulation for MER. Results Near complete revascularization with minimal distal thrombus material beyond endovascular reach corresponding to a TICI 2C degree of revascularization was achieved. Closure of the femoral puncture site was performed using an Angio seal femoral closure device. Surgical closure of the puncture site was performed by vascular surgery. The patient was eventually discharged to short term acute rehabilitation and continues to follow up outpatient with the Stroke clinic. Conclusion Older patients with ischemic stroke commonly have tortuous vessels or peripheral vascular disease. As a result, they may greatly benefit from emergent direct carotid access, as the trans‐femoral approach often poses challenges in accessing the thrombus. For patients with complex and unfavorable vascular anatomy for mechanical endo‐vascularization, direct percutaneous carotid puncture can be advantageous, effectively reducing the aforementioned difficulties. When opting for such an approach it is vital to factor in the aortic arch appearance and its branches.

Endovascular treatment for scalp arteriovenous fistulas: prospects and dilemmas.

Scalp arteriovenous fistula (AVF) is an anomalous arteriovenous connection without a capillary bed. For symptomatic scalp AVFs, an appropriate treatment must be chosen. Currently, endovascular treatment (EVT) can serve as an alternative to surgical excision. However, EVT of scalp AVFs constitutes a challenge. A standard EVT strategy for scalp AVFs has not yet been established. Therefore, a review of current research on EVT for scalp AVFs is essential. In this review, the following issues were discussed: scalp vessel anatomy; etiology, angioarchitecture and classification of scalp AVFs; EVT principles and techniques; and EVT complications and prognosis. In addition, we attempted to propose a feasible grading system with 4 grades. Based on the literature review and our experience, we found that scalp AVFs have a complex angioarchitecture, which made EVT only possible in specific cases with low-grade scalp AVFs. EVT can be performed by transarterial or transvenous embolization. Direct puncture embolization can also be used for scalp AVFs. Complete occlusion of scalp AVF by EVT had low complication and recurrence rates and a good prognosis.

Radiopharmaceutical administration practices—Are they best practice?

BackgroundThe nuclear medicine community has stated that they are using best practices to gain venous access and administer radiopharmaceuticals, and therefore do not contribute to extravasations. We tested this hypothesis qualitatively and quantitatively by evaluating four different perspectives of current radiopharmaceutical administration practices: (1) clinical observations of nuclear medicine technologists on the job, (2) quality improvement (QI) projects, (3) a high-level survey of current practices in 10 acute care hospitals, (4) intravenous (IV) access site data for 29,343 procedures. These four areas were compared to the gold standard of pharmaceutical administration techniques.ResultsFrom clinical observations of radiopharmaceutical administrations in adult populations, technologists extensively used 24-gauge peripheral intravenous catheters (PIVCs) and butterfly needles. They also performed direct puncture (straight stick). Technologists predominantly chose veins in areas of flexion (hand, wrist, and antecubital fossa), rather than forearm vessels for IV access placement; in many circumstances, antecubital fossa vessels are chosen first, often without prior assessment for other suitable vessels. For selecting the injection vein, technologists sometimes used infrared vein finders but primarily performed blind sticks. Review of QI projects suggested that smaller gauge needles were contributing factors to extravasations. Additionally, the review of surveys from 10 hospitals revealed an absence of formalized protocols, training, knowledge, and skills necessary to ensure the safety/patency of IV devices prior to the administration of radiopharmaceuticals. Finally, findings from a review of IV access data for 29,343 procedures supported the observations described above.ConclusionsWe expect that nuclear medicine technologists have the best intentions when providing patient care, but many do not follow venous access best practices; they lack formal protocols, have not received the latest comprehensive training, and do not use the best placement tools and monitoring equipment. Thus, the presumption that most nuclear medicine technologists use best practices may not be accurate. In order to improve radiopharmaceutical administration and patient care, the nuclear medicine community should update technical standards to address the most recent peripheral IV access and administration best practices, provide technologists with vascular visualization tools and the proper training, develop and require annual vascular access competency, and provide active monitoring with center and patient-specific data to create ongoing feedback.

Direct Transverse Sinus Puncture for Transvenous Coil Embolization of Vein of Galen Malformations: Innovating Existing Techniques.

Vein of Galen malformations (VOGMs) are complex arteriovenous malformations in neonates and young children. Recent advances in endovascular interventions have drastically improved treatment and clinical outcomes in what was previously high-morbidity, high-mortality disease. The high-flow shunt pathophysiology in VOGMs can lead to dynamic changes in the malformation angioarchitecture, and over time patients can develop jugular bulb stenosis. In the setting of inaccessible transvenous access to the malformation for endovascular embolization in cases where transarterial embolization is inadequate, a combined surgical and endovascular technique must be used. We present the first successful modern-day application of direct puncture through transverse sinus for transvenous embolization of a VOGM. We present 2 unique cases of complex VOGM malformations in patients who had previously undergone staged endovascular embolization for reduction of flow within the malformation. On follow-up, in both cases, there was development of severe sigmoid sinus and jugular bulb stenosis, increasing intracranial venous congestion and causing marked clinical deterioration. The stenosis prevented traditional transvenous access and treatment. We describe a direct puncture transverse sinus access using a burr hole approach for endovascular transvenous embolization in both cases with successful clinical outcomes. Direct access using burr hole craniotomy to the transverse sinus for transvenous endovascular embolization is a safe approach in the setting of severe jugular bulb stenosis for treatment of VOGMs. This technique can be done efficiently to achieve complete flow elimination in the malformation, in cases where that is called for, without significant risks or complications related to the approach.

Direct puncture versus contralateral femoral artery approach for catheter-directed thrombolysis of occluded infra-inguinal arterial bypass grafts

To compare the safety, effectiveness, and clinical outcome of percutaneous direct puncture approach versus contralateral femoral native vessel approach for catheter-directed thrombolysis of occluded infra-inguinal bypass grafts. A retrospective analysis was performed comprising a cohort of patients who underwent catheter-directed thrombolysis procedures of occluded infra-inguinal bypass grafts between January 2013 and January 2022, with a follow-up period until June 2022. This included 55 procedures via the native vessel approach and 18 procedures via the direct puncture approach. Primary outcomes were technical success and procedural safety; secondary outcomes included re-intervention rate, limb salvage, and mortality as assessed by log-rank testing and Kaplan-Meier curves. There were no differences between the two groups with regard to patient demographics, except for the number of previous vascular procedures (n=6.83±3.07 direct approach versus n=4.96±2.79 native vessel approach, p=0.025). Thrombolysis was comparably successful in both groups (n=13/18; 72% direct approach versus n=42/55; 76%, p=0.723). There were no differences in the duration of thrombolysis administration. The rate of adverse events was slightly lower in the direct approach group, but without significance (p=0.092). There were no adverse events related to the puncture site in the direct approach group. No differences were found between the time-to-event values for re-occlusion, re-intervention, amputation, or mortality respectively (p=0.662; p=0.520; p=0.816; p=0.462). The direct puncture approach seems to be a safe and efficient approach for catheter-directed thrombolysis procedures in infra-inguinal occluded bypass grafts, with clinical outcomes comparable to the native vessel approach.

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.