Markus A. Möhlenbruch

Dominik Vollherbst

Endovascular therapy has become the treatment of choice for most dural arteriovenous fistulas (dAVFs) and has considerably improved in recent years, which can be attributed to—among other factors—the introduction of new treatment techniques. A variety of endovascular treatment techniques are currently being used, such as a transarterial, transvenous, or combined approach. In special situations, especially in patients with lateral dAVFs with multiple arterial feeders, transient occlusion of the venous sinus using a balloon catheter can be used as an adjunct to conventional transarterial embolization.

Transarterial embolization in combination with transvenous balloon protection is a promising approach for the effective treatment of dAVFs because it can facilitate the embolization of the multiple feeders and prevent nontarget embolization of the venous sinuses and normal superficial veins. So far, only a few studies on this technique with relatively small numbers of patients are available.^1,2

Given this context, we decided to perform a retrospective study of our prospectively maintained patient data base to identify patients who were treated with this specific technique. We demonstrated the feasibility, effectiveness, and safety of transarterial embolization in combination with transvenous balloon protection in 22 patients with an overall complete occlusion rate of 86.4% and a permanent complication rate of 0%.

Although this patient number is relatively low, to the best of our knowledge, this is currently the largest study reporting on this treatment technique. Studies with higher patient numbers and long-term follow-up are now necessary to further assess the value of this treatment technique.

With regard to our clinical practice, and after these positive results, we have tried to broadly use transarterial embolization in combination with transvenous balloon protection whenever it has been technically feasible and appropriate, with regard to the specific angioarchitecture of the dAVF that was to be treated. In future studies, we will further investigate new treatment techniques for intracranial vascular malformations with regard to new embolic agents, new catheters, and the combination of established treatment techniques, such as combined transarterial-transvenous approaches. Furthermore, we plan to analyze our data base of patients with dAVFs, focusing on the influence of angioarchitectural features on the treatment success of endovascular embolization.

References

1. Piechowiak E, Zibold F, Dobrocky T, et al. Endovascular treatment of dural arteriovenous fistulas of the transverse and sigmoid sinuses using transarterial balloon-assisted embolization combined with transvenous balloon protection of the venous sinus. AJNR Am J Neuroradiol 2017;38:1984–89, 10.3174/ajnr.A5333.
2. Ertl L, Bruckmann H, Kunz M, et al. Endovascular therapy of low- and intermediate-grade intracranial lateral dural arteriovenous fistulas: a detailed analysis of primary success rates, complication rates, and long-term follow-up of different technical approaches. J Neurosurg 2017;126:360–67, 10.3171/2016.2.JNS152081.

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