March-April 2019

Endovascular Treatment of dAVF of the Transverse and Sigmoid Sinus Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus

Pasquale Mordasini, MD

Pasquale Mordasini

Over the past few decades, endovascular embolization has become the first-line treatment for a wide range of dural arteriovenous fistulas. Treatment of dural arteriovenous fistulas of the transverse and sigmoid sinuses by endovascular means offers a minimally invasive treatment approach; however, it is often challenging due to the anatomic complexity of the lesions. Several transarterial and transvenous endovascular approaches have been advocated, including sacrificing the recipient sinus by occlusion.

Transvenous balloon protection of the recipient venous sinus using large, compliant, dedicated dimethyl sulfoxide-resistant balloons has been reported previously. This approach protects the lumen of the recipient sinus and prevents inadvertent occlusion and propagation of liquid embolic material into adjacent cortical or deep cerebral veins. The introduction of double-lumen balloon microcatheters, which allow immediate control of the antegrade penetration of the liquid embolic agent from the arterial feeder without the need for proximal plaque formation, and at the same time avoid reflux of the embolic agent, has further facilitated endovascular treatment.

By combining the advantages of both techniques, transarterial balloon-assisted embolization and concomitant transvenous balloon protection have definitively changed our practice on how we treat dural arteriovenous fistulas to the transverse and sigmoid sinuses. They have enabled us to treat these complex lesions more safely, with low complication rates, and more efficiently, with a high rate of occlusion and remission of clinical symptoms—even allowing the preservation of venous sinus patency—and have therefore become our first-line treatment strategy.

Since we had the chance to publish our initial experience using this combined technique with promising results, we have had very encouraging feedback from several interventional colleagues all over the world who are adopting the same strategy for the treatment of dural arteriovenous fistulas of the transverse and sigmoid sinuses, with the same good results and low complication rates.

For the future, we are looking forward to further technical improvements to double-lumen balloons for transarterial liquid embolic agent injection, with a lower profile than the currently available devices. Hopefully, this will allow for navigation into even smaller and more tortuous feeding arteries, which is currently the main limitation of this treatment approach. New liquid embolic agents may also contribute to improvements and help to further facilitate embolization treatment.

We presented the technique and the results of the study at the 2017 Joint Annual Meeting of the Swiss Society of Neuroradiology and the Swiss Society of Neurosurgery in Bern, Switzerland.

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