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Cerebral Dural Arterio-Venous Fistula – Part II: Endovascular Therapy with Transarterial Embolization using Liquid Embolization Material

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Case Report | DOI: https://doi.org/10.31579/2692-9406/130

Cerebral Dural Arterio-Venous Fistula – Part II: Endovascular Therapy with Transarterial Embolization using Liquid Embolization Material

  • Michael Hofko 1*
  • Michael Sonnberger 2
  • Franz A. Fellner 1,3

1 Central Radiology Institute, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria.
2 Institute of Neuroradiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria.
3 Medical Faculty of the Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen,Germany.

*Corresponding Author: Michael Hofko, Central Radiology Institute, Kepler University Hospital, Medical Faculty of the Johannes Kepler University, Linz, Austria.

Citation: Michael Hofko, Michael Sonnberger, Franz A. Fellner, (2022), Cerebral Dural Arterio-Venous Fistula – Part II: Endovascular Therapy with Transarterial Embolization using Liquid Embolization Material. Biomedical Research and Clinical Reviews, 7(4); DOI:10.31579/2692-9406/130

Copyright: © 2022, Michael Hofko, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 08 August 2022 | Accepted: 29 September 2022 | Published: 26 December 2022

Keywords: cerebral dural arterio-venous fistula; digital subtraction angiography; endovascular; interventional radiology; embolization; onyx; transfemoral angiography; computer tomography (CT)

Abstract

Case report of a 60 years old male patient with recent diagnosisof an occipital dural arteriovenous fistula classified CognardTyp IV, treated by transfemoral cerebral angiography and embolization with liquid embolization material (Onyx).

Introduction

Dural arteriovenous fistula (DAVF) is a type of AVM in which there is a communication between dural arteries and cerebral venous sinuses. These lesions constitute 10–15% of all cerebral AVMs and most of them seemed to be acquired, only some are congenital. There is a female to male ratio of 2:1 and most of them are diagnosed in the fifth and sixth decade. The distinguishing feature between DAVF and cerebral AVM is the fact that there is no parenchymal nidusand there is a dural arterial supply[1].

We demonstrate a case of a 60 year old man with recent diagnosis of an occipital dural arteriovenous fistula classified Cognard Typ IV, treated by transfemoral cerebral angiography and embolization with liquid embolization material (Onyx - composed of a mixture of ethylene–vinyl alcohol copolymer suspended in the solvent dimethyl sulfoxide (DMSO) – Tantalumis added for radiopacity).

Case Report

We present a case of a 60-year old male patient with recent diagnosis of an occipital dural arteriovenous fistula classified Cognard Typ IV, treated by transfemoral cerebral angiography and embolization with liquid embolization material (Onyx).

The therapeutic angiography was performed in intubation anesthesia, our interventional neuroradiologist took the commonfemoral artery as an arterialaccess supported by a 6-F-vascular lock, a 6-F-guiding catheter was positioned in the left maxillary artery (Figure 1), furthermore a distal access catheterwas placed at the branchpoint of the middle meningeal artery(Figure 2). Using this guiding catheter a microcatheter was positioned at the origin of thefistula.

Figure 1: showing the catheter in the left maxillary artery a) ap position; b) side view

Figure 2: a/b showing the distal accesssecond catheter (ACCESS®) at the branch point of the middle meniongeal artery

Figure 3: a positioning of the microcatheter in front of the arterial feeders; b digital subtraction angiography showing the veinsonyx cast with complete obliteration of the fistula

Figure 4: a/b (a ap-view;b side view) digital subtraction angiography of the left commoncarotid artery showing noresidual fistula.

Discussion

Our used technique of transarterial embolization is ideally used for high- grade DAVFs, such as those with direct cortical venous drainage, or in situations in which venous access is limited. There is a list of the advantages of the transarterial embolization technique:

(1) there is the possibility to occlude the arteriovenous fistulatransition through a transarterial approach, decreasing the possibility of flow diversion into an alternate venouspathway.

(2) using this technique there is no limitation by venous access(e.g., stenotic or thrombosed venous sinuses).

(3) after the arterial pathway there is no higherrisk of venous complications.

(4) transvenous embolization can be followed by secondary site as de novo DAVFs resulting of venoushypertension.

(5) by this technique specific complications to transvenous routes can be avoided (e.g., abducens nerve palsy from catheterization of the superior petrosal sinus). [1]

Using as superselective microcatheter angiography, three-dimensional, rotational angiography and a form of high-resolution flat-panel computed tomography (CT) known as “DynaCT” are recommended in defining the arterial and venous anatomyof a DAVF both before and after embolization. To prevent premature polymerization and contamination of diagnostic catheters and solutions, embolic agents such as Onyx should be handled on a separatetable when not in use, furthermore a separate set of gloves should be used prior to handling these agents and at the end of the procedure prior to final diagnostic angiography. [1]

Onyx is one possibility of liquid embolization, it is composedof a mixture of ethylene–vinyl alcohol copolymer suspended in the solvent dimethyl sulfoxide (DMSO) – Tantalum is added for radiopacity- and first reports were published in the 1990, this drug isavailable in Europe since 1999.

Transarterial embolization technique is recommendin dural arteriovenous fistulas Cognard Typ IIb – V.

Classification of dural arteriovenous fistulas (Cognard):

INormal antegrade flowinto dural sinus
II
  1. Retrograde flowinto sinus(es)
  2. Retrograde filling of cortical vein(s)
  3. Retrograde drainage into sinus(es) and cortical veins
IIIDirect drainage intocortical veins withoutvenous ectasia
IVDirect drainage into cortical veins with venousectasia >5 mm and 3x larger thandiameter of draining vein
VDrainage to spinal perimedullary veins

[2] There are some technical advantages by using ONYX:

  1. less operatordependence from the interventional radiologist.
  2. No wedged microcatheter positionis required.
  3. Different feederscan be occluded with a single injection from a singlepedicle.

For planning the intervention the following pointsshould be considered.

  1. Where is the location of the point/points of the fistula?
  2. Location of the feedingarteries?
  3. How is thevenous drainage pattern?
  4. Where are the most promising pedicles to be injected?

After the embolization procedure an immediatecerebral CT scan is recommend, furthermore you should care about pain medication caused by the dural involvement and low-molecular weight heparin should be prescribed for 1 to 4 weeks to avoid venous thrombosis.[1]

Disclosure

All co-authors do not reportconflicts of interest.

References

  1. G. P. Colby, A. R. Paul, E. F. Ciceri, and A. L. Coon, “Chapter 90 – Endovascular Management of Dural Arteriovenous Fistulas,” 2012.
    View at Publisher | View at Google Scholar
  2. P. Jabbour et al., “Endovascular Treatment of Cerebral Dural and Pial Arteriovenous Fistulas,” Neuroimag Clin N Am, vol. 23, pp. 625–636, 2013,
    View at Publisher | View at Google Scholar
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