Peer-Review ReportA Treatment Option for Nontraumatic Adult-Type Dural Arteriovenous Fistulas: Transarterial Venous Coil Embolization
Introduction
Intracranial nontraumatic adult dural arteriovenous fistulas (DAVFs) (spontaneous DAVFs) may cause a variety of neurological symptoms. Both the symptoms and the venous drainage patterns should factor into the choice of treatment 11, 21, 22. Several therapeutic approaches for endovascular treatment have been proposed, including surgery, radiosurgery, and embolization, the latter being most often considered as the first-line treatment. Endovascular treatment can be done via the transarterial or transvenous approach 2, 4, 23.
In endovascular treatment of nontraumatic adult DAVFs, obliteration of the venous outlet, when made feasible by the available access route, is safe and highly effective for achieving a complete recovery. Where possible, retrograde, transvenous occlusion of the most proximal venous outlet represents the ideal endovascular option for curative treatment of DAVFs; however, such an approach is not always feasible, as in the case of an isolated sinus or a dural venous sinus occlusion 13, 21. In these cases, transarterial embolization is the next best endovascular treatment option. In this procedure, the usual approach is from the arterial side, and a liquid embolic agent is used to occlude the artery, fistula, and proximal part of the cortical vein. Liquid agents, e.g., glue or Onyx (ev3, Irvine, CA), are less controllable than coils and thus may present a higher risk 1, 13, 15, 19. However, the transarterial approach in which coils are passed through the fistulous site into the sinus has been rarely performed for the treatment of DAVFs because it is thought to be difficult to navigate the microcatheter through the fine vascular network of the fistula area. To our knowledge, this method has only been used in 4 cases of DAVF 3, 9, 10, 13, 21.
Here we report 4 cases of nontraumatic adult DAVFs that were obliterated using transarterial coil embolization of the proximal venous outlet. We reviewed 8 cases (4 cases in our series and 4 cases in the literature) and propose another angioarchitectural classification and treatment option for nontraumatic adult DAVFs.
Section snippets
Patients
We reviewed 8 patients who had undergone transarterial coil embolization of the proximal venous outlet for the treatment of nontraumatic adult-type DAVF (4 cases in our series and 4 in the literature). Five patients were men, and 3 were women. Their ages ranged from 18 to 71 years, with a mean of 52 years.
Angiography and Intervention Procedures
All 4 patients in our series underwent complete physical and neurological examination before and immediately after the endovascular intervention. Written informed consent for the endovascular
Patients
The clinical presentations were exophthalmos (2 cases), dizziness (1 case), seizure (1 case), headaches (1 case), trigeminal neuralgia (1 case), tinnitus (1 case), and vision loss (1 case). Two patients had received embolization once previously. The previous technique used was arterial embolization with particles in 1 patient from the literature and with Onyx in 1 patient in our series.
Angiographic Findings
Fistulas were located at the sigmoid sinus (3 cases), superior sagittal sinus (2 cases), tentorium (1 case),
Discussion
Arteriovenous fistulas involving the dural and the epidural spaces include the following: dural sinus malformation, nontraumatic infantile dural arteriovenous shunts, nontraumatic adult dural arteriovenous shunts, traumatic epidural arteriovenous communication, and induced dural arteriovenous shunts (12). Among the various DAVFs, nontraumatic adult DAVFs (spontaneous DAVFs) have a slow flow, with no angiographic evidence of steal and a complex arterial network with multiple arteriovenous shunts
Conclusions
If a smooth and distally enlarged dural artery is seen among the multiple feeding arteries, it is likely that there is a large fistula (arteriovenous fistula) that can be used as the access route for transarterial venous coil embolization. This may offer an effective and safe treatment over other endovascular approaches in specific cases.
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Distally Enlarged Feeding Artery Phenomenon in Intracranial Dural Arteriovenous Fistula: Alternative Access Route to Transarterial Intravenous Embolization
2017, World NeurosurgeryCitation Excerpt :From the pathophysiologic perspective of endovascular treatment, transvenous (TV) occlusion of the draining venous outlet is ideal.8,9 However, anatomic variations such as an isolated sinus, anatomy that is hostile to catheterization of veins, and multiple arterial feeders might prohibit this approach.10 In such cases, the next best option would be the transarterial (TA) approach to the fistulous point and diseased sinus.9-12
Endovascular treatment of intracranial dural arteriovenous fistulas
2014, World NeurosurgerySphenoid dural arteriovenous fistulas
2021, Neurosurgical ReviewA dural fistula with atypical revelation
2020, Annales Francaises de Medecine d'UrgenceToward a better understanding of dural arteriovenous fistula angioarchitecture: Superselective transvenous embolization of a sigmoid common arterial collector
2018, American Journal of Neuroradiology
Conflict of interest statement: This work was supported by a 2-year research grant of Pusan National University.