Remora Technique to Approach the Affected, Difficult to Approach Sinus at Transvenous Embolization for Dural Arteriovenous Fistulae

BACKGROUND AND IMPORTANCE: We describe a novel technique that uses a goose neck snare for microcatheterization at transvenous embolization (TVE) for dural arteriovenous fistulae (dAVF). We have named our method the “remora technique.” CLINICAL PRESENTATION: A 48-year-old man reported with dizziness. Angiography disclosed a transverse-sigmoid sinus (T-SS) dAVF with proximal sigmoid sinus occlusion, an open distal transverse sinus, narrow multiple divided confluence sinus, and multiple retrograde leptomeningeal venous drainage. We attempted TVE via the confluence sinus from the contralateral open side; it was narrow, steep, and divided into cavities, rendering the procedure very difficult. Although we were able to pass a 0.035-inch guidewire to the affected transverse sinus, we could not advance via the same route with the microguidewire. One month later we attempted transfemoral TVE again using the remora technique. We caught the 0.035-inch guidewire in the left internal jugular vein with a goose neck micro snare bearing a microcatheter. By advancing the 0.035-inch wire across the confluence sinus to the affected sinus, we were able to pass the microcatheter through the lesion using the snare like a remora. We then performed transvenous coil packing. CONCLUSION: In TVE for dAVF, passage of the microguidewire is often difficult. Even if the affected sinus can be reached with the stiff 0.035-inch guidewire, it may not be possible to follow with the microguidewire. We report on a patient with T-SS dAVF who underwent successful microcatheterization in which we used our remora technique with a goose neck snare.