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*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)
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).
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).
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.
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):
| I | Normal antegrade flowinto dural sinus |
| II |
|
| III | Direct drainage intocortical veins withoutvenous ectasia |
| IV | Direct drainage into cortical veins with venousectasia >5 mm and 3x larger thandiameter of draining vein |
| V | Drainage to spinal perimedullary veins |
[2] There are some technical advantages by using ONYX:
For planning the intervention the following pointsshould be considered.
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]
All co-authors do not reportconflicts of interest.
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