Retrograde transvenous embolization of a tentorial dural AV-Fistula

Patient situation

• This 65-year-old patient presented with an acute subarachnoid hemorrhage (H&H Grade 1, modified Fisher Grade 3). There was a subtle increased vascular patterning in the right cerebellar hemisphere with otherwise normal CTA.
• DSA revealed a right-sided tentorial dural arteriovenous fistula with feeders from the meningohypophyseal trunk (MHT). Venous drainage involved a superficial pial cerebellar venous pouch (superomedially) and the superior petrous sinus (SPS, laterally).

Treatment chosen

• Venous access: left jugular 8f Guider Soft Tip and React 0.068 (cross-over) in the right transverse sinus, Scepter XC 4 x 11 mm dual lumen balloon in the right SPS
• Arterial access: 6F Envoy XB and Eclipse SL 6 x 7 mm for proximal balloon protection

Transarterial and transvenous injection

• Retrograde contrast injection via Scepter XC balloon confirming correct position close to the fistula.
• Systolic blood pressure was lowered below 100mmHg. Retrograde embolization using Onyx 20 via inflated Scepter XC balloon with subsequent filling of the venous pouch (video).

Results

• Retrograde transvenous embolization using a dual lumen (EVOH-compatible) balloon can be an option in tentorial dural arteriovenous fistulae.
• The React 0.068 was used as a stable platform in the right transverse sinus with “cross-over” access from the right femoral vein.
• In this case, complete occlusion of the fistula was achieved with a minimal amount (0.2ml) of Onyx 20.
• Patient was discharged with no deficit.

Supported by Medtronic