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Transvenous balloon-assisted approach to anterior fossa dural arteriovenous fistula using retrograde pressure cooker technique
  1. Alex Devarajan,
  2. Christina P Rossitto,
  3. Mais Al-Kawaz,
  4. Brian Giovanni,
  5. Vikram Vasan,
  6. Tomoyoshi Shigematsu,
  7. Alejandro Berenstein,
  8. Johanna T Fifi
  1. Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Mr Alex Devarajan; alex.devarajan{at}icahn.mssm.edu

Abstract

Endovascular embolization is the first-line therapy for dural arteriovenous fistulas (dAVFs). Transarterial embolization (TAE) may be limited by poor anatomical access. Transvenous embolization avoids this, but carries a risk of hemorrhage, venous redirection, and neurologic deterioration. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA, USA) provide flow arrest and prevent reflux during TAE with liquid embolic agents (LEAs), but use in the distensible veins may be challenging. In this video, we use a Scepter Mini in a transvenous approach to a Cognard type IV anterior ethmoidal dAVF as a safe alternative to surgery, transvenous pressure cooker, and trans-ophthalmic TAE (video 1). The Scepter Mini was navigated transvenously to the anterior superior sagittal sinus. LEA was injected with excellent penetration to the venous pouch and further penetration into the network of tortuous feeders. No neurologic complications were experienced, and follow-up angiogram 9 months later demonstrated cure of the dAVF. Video 2 describes procedural considerations in transvenous approaches, steps of the procedure, and includes references1–10 which are relevant to this topic.

Video 1

Video 2
  • Fistula
  • Arteriovenous Malformation
  • Balloon
  • Catheter
  • Liquid Embolic Material

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Footnotes

  • X @AlexDevarajan, @cprossitto, @Mais_Alk

  • Contributors Conceptualization: AD, JTF. Initial drafting: AD, MAK, BG, JTF. Narration: AD. Performed procedure: MAK, AB, JTF. Critical review: AD, CPR, MAK, BG, VV, TS, AB, JTF. Supervision: TS, AB, JTF.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer JTF is a member of the Society of NeuroInterventional Surgery Board of Directors.

  • Competing interests AB: consulting fees - Microvention. JTF: consulting fees - Microvention; leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid - Society of NeuroInterventional Surgery Board of Directors.

  • Provenance and peer review Not commissioned; externally peer reviewed.