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.