The Procedure-Related Complications of Transarterial Onyx Embolization of Dural Arteriovenous Fistula Using Transvenous Balloon Protection

doi:10.1016/j.wneu.2018.04.163

World Neurosurgery

Volume 116, August 2018, Pages e203-e210

https://doi.org/10.1016/j.wneu.2018.04.163 Get rights and content

Highlights

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This is the first report to emphasize the complications of balloon-assisted technique.
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Three patients suffered complications, including epidural hemorrhage, intracerebellar hemorrhage, and cerebellar infarction.
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We think it's valuable to analyze such cases to increase the safety of the transvenous balloon protection technique.

Objective

Transarterial embolizatioin with transvenous balloon protection has been described as a promising technique for intracranial dural arteriovenous fistula. The aim of our study was to report our preliminary experiences of this technique with regard to its safety and efficacy and to emphasize the procedure-related complications.

Methods

Fourteen consecutive patients with dural arteriovenous fistula were treated with a transvenous balloon–assisted technique between March 2014 and November 2017. All lesions were embolized with Onyx via a transarterial approach with sinus balloon protection to preserve the patency of the dural sinus. Clinical and angiographic data were retrospectively collected and the occlusion rate, complications, and clinical outcome were analyzed.

Results

All 14 patients were symptomatic on admission, mean age was 40.9 years, and 9 (64.3%) of them were men. Thirteen patients had a single fistula at transverse-sigmoid sinus (n = 10) or superior sagittal sinus (n = 3), and another patient had multiple fistulas located at SSS/tentorium. Two patients presented with Cognard type I fistula, 12 with Cognard type II (IIa:6;IIb:1;IIa + b:5). Complete (8/11) or near-complete (3/11) occlusion was achieved in 11 patients (78.6%). Procedure-related complications occurred in 3 cases, including 1 epidural hemorrhage, 1 cerebellar hemorrhage, and 1 cerebellar infarction. At latest clinical follow-up (mean: 13 months), symptoms were resolved on 6 patients, relieved in 7 patients, and deteriorated in 1 patient.

Conclusions

The transvenous balloon protection offers an alternative to treat complex dural arteriovenous fistula, but further investigation are needed to lower related complications.

Introduction

Intracranial dural arteriovenous fistula (DAVF) accounts for 10%–15% of intracranial arteriovenous malformations and can cause aggressive symptoms such as neurologic deficits or intracranial hemorrhage.¹ There are several methods to treat DAVF, including endovascular embolization, microsurgery, radiotherapy, or the combination of them.² With the development of liquid embolic material, endovascular embolization has become the primary treatment option.³ When the DAVFs involve major sinuses, it's difficult to achieve complete occlusion of the fistula network merely through a transarterial approach, and a venous occlusive strategy has been advocated for such a scenario. However, sacrifice of sinuses, especially the dominant ones, is associated with the risk of greater complication rates, worsening venous hypertension, and even inducing new lesions.⁴ Recently, a new transvenous balloon-assisted protection technique has been reported and showed encouraging results.5, 6, 7, 8, 9 Here, we present 14 cases treated by this technique and investigate its advantages and drawbacks.

Section snippets

Patients

One hundred eighty-four consecutive cases with symptomatic DAVFs were embolized in Beijing Tiantan Hospital and Beijing Tsinghua Changgung Hospital between March 2014 and November 2017, in which 14 cases were treated by transarterial Onyx embolization in combination with transvenous balloon protection. The criteria for use of balloon protection included: 1) Cognard type I or II; 2) fistula located at the superior sagittal sinus (SSS) or transverse-sigmoid sinus (TSS); and 3) the sinus was

Results

Clinical and angiographic characteristics are summarized in Table 1. Among all patients, 9 were male and 5 were female, and the mean age was 40.9 years (range from 17 to 60 years). All patients were symptomatic, 8 patients presented with pulsatile tinnitus, 4 with proptosis and chemosis, 1 presented mild hemiparalysis, and 1 with intracranial hemorrhage and seizure.

Angiography revealed 13 patients had a single fistula in which were 10 located at the TSS and 3 located at the SSS, and 1 patient

Discussion

DAVFs mainly involve the wall of major dural sinuses such as the TSS or SSS. With the development of embolic material, especially the use of Onyx, endovascular therapy has become the most valuable option for DAVF.¹⁰ A DAVF can be fed by multiple arteries from the external carotid artery or internal carotid artery, or even from the vertebral system. For such complex DAVF, it's difficult to occlude all fistulas on the sinus wall by a transarterial approach embolization; sometimes we need to

Conclusions

Transvenous balloon–assisted technique is helpful to improve the cure rate of the DAVF and to preserve the patency of the sinus. However, there are some risks for this technique, including hemorrhage and thrombosis. The thorough evaluation of the DAVF, strict control of the balloon dilation and Onyx injection, and careful monitoring during the procedure are very important to prevent side effects. Because of the short period and small case series, the long-term outcome and standard procedure of

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Cited by (13)

Onyx embolization of a spinal epidural hemorrhage caused by thoracic spinal epidural arteriovenous fistula: A case report and literature review
2022, Journal of Interventional Medicine
Spinal epidural hemorrhages (SEDH) caused by spinal epidural arteriovenous fistulas (SEAVFs) are rare; thus, their specific pathogenesis has not been explained. Furthermore, the standard treatment for SEAVFs has not yet been defined. Here we report the case of a 36-year-old Chinese man who experienced acute onset chest pain and tightness. His symptoms rapidly aggravated until the lower limbs were unable to support him. Spinal magnetic resonance angiography (MRA) revealed a localized SEAVF and a secondary spinal cord lesion at the T4 level. Digital subtraction angiography (DSA) confirmed the presence of the SEDH/SEAVF at the T3–4 level with the left radicular artery feeding the fistula. Based on DSA and MRA findings, SEDH, local spinal cord infarction, and spinal venous reflux disorder were conditionally diagnosed. Using the arterial route, Onyx-34 was injected into the fistula to embolize the feeding arteries and the venous system. Angiography was performed after the microcatheter was withdrawn, and no residual fistula or anterior spinal artery was observed. The six-week follow-up MRI showed acceptable healing of the SEAVF, and the patient improved neurologically. This case suggests that endovascular treatment with Onyx-34 embolization should be considered a promising treatment strategy for this type of complicated SEAVF.
Transarterial embolization in dural arteriovenous fistulas under sinus balloon protection using the SHOURYU supercompliant balloon
2022, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Transarterial embolization under intrasinus balloon protection is an efficient treatment strategy for intracranial arteriovenous fistula. Ordinary balloon protection methods using the Copernic RC balloon may occlude the normal drainage route, and the occurrence of venous complications is concerning. The aim of this study was to report the efficacy of the supercompliant SHOURYU balloon catheter for intrasinus balloon protection while preserving the normal venous outlet.
Eighteen patients with dural arteriovenous fistulas who were treated with transarterial embolization under intrasinus balloon protection between April 2011 and July 2020 were included. All lesions were treated with transarterial embolization under intrasinus balloon protection using the SHOURYU balloon catheter. Clinical and angiographic data were retrospectively collected, and the occlusion rate, complications, and clinical outcomes were analyzed.
Nine men and nine women were treated, and their average age was 61.1 years. Fistulas were located at the transverse-sigmoid sinus (n = 13), superior sagittal sinus (n = 3), tentorial sinus (n = 1), and around the torcular Herophili (n = 1). Ten patients were classified as Borden typeⅠand eight as Borden type Ⅱ. Complete (n = 9) or near-complete (n = 4) occlusion was achieved in 72.2% of the patients. Periprocedural complications, but no venous complications were observed in two patients. Symptoms were not aggravated after treatment.
Transarterial embolization under intrasinus balloon protection using the SHOURYU balloon catheter is effective and safe for treatment of dural arteriovenous fistulas while maintaining the patency of the venous sinus.
Transarterial Onyx embolization with targeted balloon-assisted sinus protection for treatment of dural arteriovenous fistula of the lateral tentorial sinus
2020, Radiology Case Reports
Citation Excerpt :
To avoid venous infarction, an inflation time of 2-5 minutes has been used [11,15] during Onyx injection; however, the most appropriate time for temporary sinus occlusion has not been established. Guo et al [12] recently reported procedure-related complications of Onyx TAE using a long sinus-protection balloon. Among 14 patients treated, 3 developed complications (epidural hemorrhage, cerebellar hemorrhage, and cerebellar infarction, respectively), which may have been caused by occlusion of cortical draining veins into the sinuses.
We present a unique sinus protection technique that uses a short-length supercompliant balloon during the transarterial Onyx embolization for the dural arteriovenous fistula (DAVF) of the lateral tentorial sinus. With this technique, we temporarily change the Borden classification from type II to type III, avoiding venous compromise and reducing the risk of Onyx migration into the patent sinus. A 54-year-old man presented with left persistent tinnitus of 4 months’ duration. Cerebral angiography revealed a Borden type II left lateral tentorial sinus-DAVF associated with retrograde cortical venous reflux draining into the vein of Labbé. In the venous phase, the ipsilateral transverse-sigmoid sinus was recognized as a functional sinus and the posterior temporal vein drained into the transverse sinus near the drainage channel. We planned to perform transarterial Onyx embolization using a short-length sinus protection balloon to protect against Onyx migration. During transarterial Onyx injection, a 7 × 7-mm HyperForm balloon was navigated into the affected sinus and positioned to cover the drainage channel from the shunt. After confirming the change in Borden classification with angiography, transarterial Onyx embolization was performed via the middle meningeal artery. This procedure resulted in complete obliteration of the fistula with good patency of both the transverse-sigmoid sinus and neighboring normal cortical veins. No procedure-related complications were observed and the patient remained free of recurrence during the 24-month follow-up period. Short-length balloon-protected Onyx embolization can be safe and effective for the treatment of Borden type II DAVF.
Factors Predicting De Novo Formation of Fistulas After Dural Fistula Embolization Using Venous Sinus Balloon Protection
2020, World Neurosurgery
Citation Excerpt :
In addition, embolization of fistula and the relevant sinus may lead to formation of de nova fistulas.5,6 Therefore, the transvenous balloon protection technique is now used more frequently for Cognrad I and II DAVFs.7,8 The technique is not completely devoid of complications, however, and is difficult to perform.
Endovascular embolization with transvenous sinus preservation using balloon is at present the preferred modality for dural arteriovenous fistulas involving venous sinuses (sagittal, transverse, and sigmoid) with potential drainage function. The aim of the study was to evaluate the necessity and medium-term efficacy of this technique.
Patients with dural arteriovenous fistulas involving large sinuses who underwent vascular embolization with transvenous balloon protection technique at our center from December 2012 to July 2017 were retrospectively reviewed. The clinical symptoms, postoperative and mid-term follow-up imaging results, perioperative complications, and follow-up clinical outcomes were analyzed.
Eighteen patients (8 women and 10 men) with mean age 49 years were included in this study. Complete (16 of 18) or near-complete (1 of 18) occlusion of original fistula was achieved in 17 patients (94.4%). Recurrence of original fistula (1 of 18) or de novo fistula (3 of 18) occurred in 4 patients (22.2%). The patency rate of balloon-protected sinus was 72.2% (13 of 18) during the follow-up, and the involved sinuses were eventually occluded in 5 patients (27.8%). The frequency of de novo fistulas was higher in patients with sinus occlusion (P < 0.05). Stenosis of the involved sinus was more likely related to balloon-protected sinus occlusion (P < 0.05). After a mean follow-up of 17.6 months, 17 patients (94.4%) achieved remission of the original symptoms.
Transvenous balloon protection technique maintains sinus patency in most cases, and preoperative stenosis increases the probability of sinus occlusion. De novo fistula is related to sinus occlusion during the follow-up.
Transarterial Embolization of Dural Arteriovenous Fistula in Superior Sagittal Sinus Under Bilateral External Carotid Artery Flow Control: Technical Note
2019, World Neurosurgery
Transarterial embolization (TAE) using liquid embolic material is a standard treatment for non-sinus-type dural arteriovenous fistula (DAVF). However, to reach embolic material over a shunt point for complete obliteration of DAVF is often difficult. We present a technical case report of the efficacy of bilateral external carotid artery (ECA) flow control for the TAE of superior sagittal sinus DAVF.
A 64-year-old man presented with dizziness and left hemiparesis. Computed tomography imaging showed right parietal subcortical hemorrhage, and cerebral angiography revealed a DAVF in the superior sagittal sinus fed by bilateral occipital artery, bilateral superficial temporal artery and bilateral middle meningeal artery (MMA), with cortical venous reflux and without connection to the superior sagittal sinus. We therefore planned TAE using glue via MMA under bilateral ECA flow control. A 7-Fr balloon guide catheter was positioned in the bilateral ECA origins, and a microcatheter was introduced distal to the MMA. Heated 20% n-butyl-2-cyanoacrylate was slowly injected via the left MMA under bilateral ECA origin flow control. The n-butyl-2-cyanoacrylate reached the shunt point and obliterated the shunt in a single session. The patient was discharged without neurological symptoms.
Bilateral ECA flow control using balloon guide catheter is safe and effective for a DAVF in the superior sagittal sinus with multiple and tortuous scalp feeders.
Current Status of Endovascular Treatment for Dural Arteriovenous Fistulas in the Superior Sagittal Sinus Region: A Systematic Review of the Literature
2019, World Neurosurgery
Dural arteriovenous fistulas (DAVFs) occurring in the superior sagittal sinus (SSS) region are difficult to cure. Endovascular treatment (EVT) is an effective method for the treatment of SSS region DAVFs. Currently, no systematic review of EVT for SSS region DAVFs is available. A systematic review of the literature is necessary.
A systematic PubMed search for studies related to SSS region DAVFs published after 1990 in English was performed on October 15, 2018.
Thirty-three studies involving 42 patients, including 31 (73.8%, 31/42) men, were finally identified. Of the 42 patients, 12 (28.6%, 12/42) patients mainly presented with intracranial hemorrhage, and 9 (21.4%, 9/42) patients presented with cognitive impairment. Of the 42 patients, 31 (73.8%, 31/42) patients were treated via transarterial embolization, and 11 (26.2%, 11/42) patients were treated via transvenous embolization. Of the 42 patients, 41 (97.6%, 41/42) patients had a clear angiographic outcome, and complete angiographic cure was achieved in 36 (87.8%, 36/41) patients. Of the 42 patients, 4 (9.5%, 4/42) patients were reported to have procedural complications. Of the 42 patients, 37 (88.1%, 37/42) patients had a definite description of the follow-up outcome, 22 (59.5%, 22/37) patients had a modified Ranking Scale score of 0, and 12 (32.4%, 12/37) patients had an improved neurologic state.
In treating SSS region DAVFs, EVT can completely obliterate the fistula point and correct venous shunting. Thus, currently EVT is an effective treatment for SSS region DAVFs. Although many complications can occur, this approach achieves good outcomes in most cases.

View all citing articles on Scopus

: Feng Guo and Yupeng Zhang are co–first authors.

: Conflict of interest statement: This work was supported by the National Natural Science Foundation of China (Grant No. 81371314) and the High-level Personnel Training Program of Beijing Health System (Grant No. 2013–2-016).

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Original ArticleThe Procedure-Related Complications of Transarterial Onyx Embolization of Dural Arteriovenous Fistula Using Transvenous Balloon Protection

Highlights

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Conclusions

Neurosurg Clin N Am

Eur J Radiol

Interv Neuroradiol

World Neurosurg

World Neurosurg

J Neuroradiol

Cranial dural arteriovenous fistula: transarterial Onyx embolization experience and technical nuances

J Neurointerv Surg

Dural arteriovenous fistulae developing at different locations after resolution of previous fistulae: report of three cases and review of the literature

Am J Neuroradiol

Endovascular therapy of low- and intermediate-grade intracranial lateral dural arteriovenous fistulas: a detailed analysis of primary success rates, complication rates, and long-term follow-up of different technical approaches

J Neurosurg

Original Article
The Procedure-Related Complications of Transarterial Onyx Embolization of Dural Arteriovenous Fistula Using Transvenous Balloon Protection