The advantages of balloon assistance in endovascular embolization of spinal dural arteriovenous fistulas

OBJECTIVE Vascular malformations of the spine represent rare clinical entities with profound neurological implications. Previously reported studies on management strategies for spinal dural arteriovenous fistulas (sDAVFs) appeared before the advent of modern liquid embolic agents. Authors of the present study review their institutional experience with endovascularly and surgically treated sDAVFs. METHODS The authors performed a retrospective, observational, single-center case series on sDAVFs treated with endovascular embolization, microsurgical occlusion, or both between 2004 and 2013. The mode, efficacy, and clinical effect of treatment were evaluated. RESULTS Forty-seven patients with spinal arteriovenous malformations were evaluated using spinal angiography, which demonstrated 34 Type I sDAVFs (thoracic 20, lumbar 12, and cervical 2). Twenty-nine of the patients (85%) were male, and the median patient age was 63.3 years. Twenty patients underwent primary endovascular embolization (16 Onyx, 4 N-butyl cyanoacrylate [NBCA]), and 14 underwent primary surgical clipping. At a mean follow-up of 36 weeks, according to angiography or MR angiography, 5 patients treated with endovascular embolization demonstrated persistent arteriovenous shunting, whereas none of the surgically treated patients showed lesion persistence (p = 0.0237). Thirty patients (88%) experienced some resolution of their presenting symptoms (embolization 17 [85%], surgery 13 [93%], p = 1.00). CONCLUSIONS Microsurgical occlusion remains the most definitive treatment modality for sDAVFs, though modern endovascular techniques remain a viable option for the initial treatment of anatomically amenable lesions. Treatment of these lesions usually results in some clinical improvement.

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Endovascular management of spinal dural arteriovenous fistulas

Neurosurgical FOCUS ◽

10.3171/2009.2.focus098 ◽

2009 ◽

Vol 26 (5) ◽

pp. E15 ◽

Cited By ~ 46

Author(s):

Walavan Sivakumar ◽

Gabriel Zada ◽

Parham Yashar ◽

Steven L. Giannotta ◽

George Teitelbaum ◽

...

Keyword(s):

Surgical Treatment ◽

Vascular Malformations ◽

Endovascular Embolization ◽

Embolic Agent ◽

Endovascular Management ◽

Arteriovenous Fistulas ◽

Spinal Vascular Malformations ◽

Embolic Agents ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

Object Spinal dural arteriovenous fistulas (DAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy, yet remain inefficiently diagnosed lesions. Over the last several decades, the treatment of spinal DAVFs has improved tremendously due to improvements in neuroimaging, microsurgical, and endovascular techniques. The aim of this paper was to review the existing literature regarding the clinical characteristics, classification, and endovascular management of spinal DAVFs. Methods A search of the PubMed database from the National Library of Medicine and reference lists of all relevant articles was conducted to identify all studies pertaining to spinal DAVFs, spinal dural fistulas, and spinal vascular malformations, with particular attention to endovascular management and outcomes. Results The ability to definitively treat spinal DAVFs using endovascular embolization has significantly improved over the last several decades. Overall rates of definitive embolization of spinal DAVFs have ranged between 25 and 100%, depending in part on the embolic agent used and the use of variable stiffness microcatheters. The majority of recent studies in which N-butyl cyanoacrylate or other liquid embolic agents were used have reported success rates of 70–90%. Surgical treatment remains the definitive option in cases of failed embolization, repeated recanalization, or lesions not amenable to embolization. Clinical outcomes have been comparable to surgical treatment when the fistula and draining vein remain persistently occluded. Improvements in gait and motor function are more likely following successful treatment, whereas micturition symptoms are less likely to improve. Conclusions Endovascular embolization is an increasingly effective therapy in the treatment of spinal DAVFs, and can be used as a definitive intervention in the majority of patients that undergo modern endovascular intervention. A multidisciplinary approach to the treatment of these lesions is required, as surgery is required for refractory cases or those not amenable to embolization. Newer embolic agents, such as Onyx, hold significant promise for future therapy, yet long-term follow-up studies are required.

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Spinal Dural Arteriovenous Fistula Presenting with Myelopathy

Cerebrovascular Neurosurgery ◽

10.1093/med/9780190887728.003.0030 ◽

2019 ◽

pp. 279-286

Author(s):

Vinayak Narayan ◽

Anil Nanda

Keyword(s):

Spinal Cord ◽

Arteriovenous Malformations ◽

Dural Arteriovenous Fistula ◽

Endovascular Embolization ◽

Spinal Dural Arteriovenous Fistula ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Degenerative Spinal Disease ◽

Spinal Arteriovenous Malformations ◽

Spinal Dural Arteriovenous Fistulas

Abstract: Spinal dural arteriovenous fistulas are a rare cause of congestive myelopathy. Symptoms are insidious in onset and may be confused with degenerative spinal disease. MRI characteristically shows edema of the spinal cord with serpiginous flow voids that follow the surface of the spinal cord. Careful evaluation with spinal angiography is required to ensure accurate diagnosis. Spinal dural arteriovenous fistulas differ from spinal arteriovenous malformations in that most fistulas have only a single fistulous point without a nidus. Spinal dural arteriovenous fistulas may be treated successfully with either surgical resection or endovascular embolization depending on their anatomy. Earlier treatment is associated with better outcomes.

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Overview of the current role of endovascular and surgical treatment in spinal dural arteriovenous fistulas

Neurosurgical FOCUS ◽

10.3171/foc.2009.26.1.e8 ◽

2009 ◽

Vol 26 (1) ◽

pp. E8 ◽

Cited By ~ 21

Author(s):

Amir R. Dehdashti ◽

Leodante B. Da Costa ◽

Karel G. terBrugge ◽

Robert A. Willinsky ◽

Michael Tymianski ◽

...

Keyword(s):

Surgical Treatment ◽

Vascular Malformations ◽

Endovascular Embolization ◽

Vascular Lesions ◽

Current Role ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Complete Obliteration ◽

Spinal Dural Arteriovenous Fistulas

Dural arteriovenous fistulas are the most common vascular malformations of the spinal cord. These benign vascular lesions are considered straightforward targets of surgical treatment and possibly endovascular embolization, but the outcome in these cases depends mainly on the extent of clinical dysfunction at the time of the diagnosis. A timely diagnosis is an equally important factor, with early treatment regardless of the type more likely to yield significant improvements in neurological functioning. The outcomes after surgical and endovascular treatment are similar if complete obliteration of the fistulous site is obtained. In the present study, the authors evaluated the current role of each modality in the management of these interesting lesions.

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Recurrence of “cured” dural arteriovenous fistulas after Onyx embolization

Neurosurgical FOCUS ◽

10.3171/2012.2.focus1224 ◽

2012 ◽

Vol 32 (5) ◽

pp. E12 ◽

Cited By ~ 35

Author(s):

Peter Adamczyk ◽

Arun Paul Amar ◽

William J. Mack ◽

Donald W. Larsen

Keyword(s):

Case Series ◽

Endovascular Embolization ◽

Arteriovenous Fistulas ◽

Contributory Factors ◽

Catheter Embolization ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas ◽

Cure Rates

Endovascular embolization with Onyx has been increasingly used to treat intracranial and spinal dural arteriovenous fistulas (DAVFs). Several case series have been published in recent years reporting high DAVF cure rates with this technique. Although it is seldom reported, DAVF recurrence may occur despite initial “cure.” The authors present 3 separate cases of a recurrent DAVF after successful transarterial Onyx embolization. Despite adequate Onyx penetration into the fistula and draining vein, these cases demonstrate that DAVF recanalization may reappear with filling from previous or newly recruited arterial feeders. Other published reports of DAVF recurrence are examined, and potential contributory factors are discussed. These cases highlight the need for awareness of this possible phenomenon and suggest that follow-up angiography should be considered in patients treated with catheter embolization.

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Dural arteriovenous fistulas draining into the petrosal vein or bridging vein of the medulla: possible homologs of spinal dural arteriovenous fistulas

Journal of Neurosurgery ◽

10.3171/2009.1.jns08840 ◽

2009 ◽

Vol 111 (5) ◽

pp. 889-899 ◽

Cited By ~ 36

Author(s):

Yutaka Mitsuhashi ◽

Thaweesak Aurboonyawat ◽

Vitor Mendes Pereira ◽

Sasikhan Geibprasert ◽

Frédérique Toulgoat ◽

...

Keyword(s):

Endovascular Embolization ◽

Venous Hypertension ◽

Venous Reflux ◽

Male Predominance ◽

Arteriovenous Fistulas ◽

Petrosal Vein ◽

Therapeutic Choice ◽

Dural Arteriovenous Fistulas ◽

Bridging Vein ◽

Spinal Dural Arteriovenous Fistulas

Object Dural arteriovenous fistulas (DAVFs) with leptomeningeal venous reflux generally pose a high risk of aggressive manifestations including hemorrhage. Among DAVFs, there is a peculiar type that demonstrates direct drainage into the bridging vein rather than the dural venous sinus. The purpose of this study was to investigate the characteristics of DAVFs that drain directly into the petrosal vein or the bridging vein of the medulla oblongata. Methods Eleven consecutive cases of DAVFs that drained directly into the petrosal vein and 6 that drained directly into the bridging vein of the medulla were retrospectively reviewed. These cases were evaluated and/or treated at Hospital de Bicêtre in Paris, France, over a 27-year period. A review of previously reported cases was also performed. Results Both of these “extrasinusal”-type DAVFs demonstrated very similar characteristics. There was a significant male predominance (p < 0.001) for this lesion, and a significantly higher incidence of aggressive neurological manifestations including hemorrhage or venous hypertension than in DAVFs of the transverse-sigmoid or cavernous sinus (p < 0.001). This finding was considered to be attributable to leptomeningeal venous reflux. Regarding treatment, endovascular embolization (either transarterial or transvenous) is frequently difficult, and surgery may be an effective therapeutic choice in many instances. Conclusions Embryologically, both the petrosal vein and the bridging vein of the medulla are cranial homologs of the spinal cord emissary bridging veins that drain the pial venous network. The authors believe that DAVFs in these locations may be included in a single category with spinal DAVFs because of their similar clinical characteristics.

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Endovascular Embolization of a Lateral Sacral Fistula: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa020 ◽

2020 ◽

Vol 19 (3) ◽

pp. E313-E313

Author(s):

Rudy J Rahme ◽

Karl R Abi-Aad ◽

Ahmad Kareem Almekkawi ◽

Devi P Patra ◽

Bernard R Bendok

Keyword(s):

Vascular Malformations ◽

Spastic Paraparesis ◽

Endovascular Embolization ◽

Delay In Diagnosis ◽

Arteriovenous Fistulas ◽

Key Points ◽

Dural Arteriovenous Fistulas ◽

Internal Iliac ◽

Spinal Dural Arteriovenous Fistulas

Abstract Spinal dural arteriovenous fistulas are the most common vascular malformations of the spine. They are localized in the sacral spine in 5% to 14% of the cases. They can be fed by the median or the lateral sacral arteries. These lesions present with nonspecific symptoms such as radiculopathy and/or myelopathy, which often leads to a delay in diagnosis. In this video, we present the case of a 65-yr-old gentleman with a lateral sacral dural arteriovenous fistula. The patient was referred to our institution after the outside facility workup was nondiagnostic. He presented with spastic paraparesis and bilateral radiculopathy. After patient informed consent was obtained, we performed a spinal diagnostic angiogram with catheterization and angiography of the internal iliac artery, which revealed the fistula. Onyx (Medtronic, Dublin, Ireland) embolization was performed, which led to a complete occlusion of the fistula. The patient had complete neurological recovery, and at 2-yr follow-up, imaging remained negative for a fistula. In this video, we discuss the nuances and key points related to the epidemiology, diagnosis, and treatment of lateral sacral fistulas.1-3

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