Innumerable Dural Fistulas Superselective Transvenous Cure

As much as we talk about superselective transvenous embo, one can argue that there are many ways to skin the cat.  Transarterial often ain’t pretty, and also more hazardous as a rule, but it usually works.  Many superselectives are simple grade 1s that one might even consider watching.  The real test comes when there are no other good options — then all the training pays off…

Presentation is with progressive somnolence.   The family began to notice a strange pulsating noise coming from the head, loud enough for big apple to hear.

Right ECA — these are not DYNAs — they are MIPs of 5 second rotational angio 3D DSA.  Same flat panel CT stuff, different name.  Why not DYNAs?  Too much radiation, and 3D DSA MIPS are usually good enough

Right-sided fistula pouches / common channels

Big one on the left

Analysis — not this time.  Too much to talk about.  The bottom line is that sinus sacrifice is not an option and there are tons of shunts.   The SSS must be returned to its duty, and the other sinus must be kept open.

Realistic options with these requirements are transarterial embo with balloon / stent sinus protection or superselective transvenous.  We prefer the latter

Now it begins

Transvenous fistula pouch/channel catheterization

STA control

Coils via Scepter C — angioplasty at site of sinus stenosis. Still alive after coils

Adding Onyx — should have started with that

more plasty

On to the proximal SSS channel.  Some shenanigans are needed to bounce the one tip headway duo against the balloon and enter the channel

Used coils because it was not a Scepter.  Probably should have used Onyx also. Notice how predictably the SSS has stenoses near the fistulas — high-flow venopathy

Not much use of the SSS by the brain at this point

However… What’s happening here?

On to the next channel — insets show visualization via MIPs and subclavian injection — putting it together

Here we get into an issue with some Onyx in the sinus

Came out with a Solumbra…

Making progress

Another channel

Now that we are almost done on the right, another channel pops into view -not well-seen on initial MIPs.  It is better delineated now because the other exit of this channel (in the distal right transverse sinus) was the one plugged up by the onyx that then escaped into the sinus.

Some more SSS plasty

Not bad so far — look how much better the right side is draining, all with strategic “magic  bullet” embo

Now to the left

Big channel here (arrow) with two openings

An 027 Via in a big channel — injection thru via — see the second, distal opening?

Now for the mistake — bad choice of embolization material.  Creative yes

Effective no

made an easy thing difficult. Almost no purchase into the channel now, so Onyx will not do.  Glue did as well as it could, even got into the distal opening a bit.  Some came back and got plastered along the sinus walls also. The balloon squished it some before it popped

success!… 🙁

Still, drainage is better…

Right side is reasonable

Still got that good channel to look forward to

End of act 1.  Time to go home…

Act 2 — next day

Better here also.  And all pial-dural anastomoses are gone…

Posterior condylar part — always nice ascending pharyngeal anatomy…

another winner for transvenous approach here — balloon keeps catheter in the posterior condular vein.  Coils and a bit of Onyx

Now for our channel — scepter points down into one of the arteries.  Injection thru the scepter on the right — balloon is down to show the channel.  Then inflate, onyx, deflate, pull back, onyx more, repeat… until filled

Second balloon in the sinus for protection

Now we try to bounce off the sinus balloon and get into that WEBBED channel…  no good — just the SPS

What now?

Its sledge time…

Pindi tuli: Sparo maneris?

Transarterial occipital coil and Onyx embo… hit ’em hard…

Now for the petrosquamosal branch.  Same old way — Scepter and Onyx… We do manage to permeate that inferior occipital channel that stayed open despite occipital embo

Typical transarterial result — lots of Onyx, fistula still open… but much smaller

Certainly better drainage.  Note how that left sigmoid sinus looks — like its narrowed by embolic material

Much better venous drainage here also.

Small bit on the right.  Not worth transarterial liquid embolic here

Overall, its excellent.  Sagittal sinus back in service, transverse/sigmoid sinuses preserved (which were needed), deep drainage nearly normalized.   Aside from the self-inflicted punishment on the left, the superselective transvenous approach saves the day.  Below is the final embo cast.  Not bad at all.

End of Act 2.

Act 3.  Six months later.  Right side is excellent

Left sigmoid has gone down.  Probably all that glue in there.

Thankfully, fistula is gone also.  We’ll take it.

Posterior fossa veins are certainly good enough

Transarterial for this last one

Good old nBCA gets the job done

This was one of the more challenging transvenous sinus-sparing cases.   I don’t think there is a better way today.  Even though left sinus was eventually lost, the patient is cured and there is perfectly adequate outflow via the left transverse.  We usually stent these at the end (of Act 2) if they look tenuous.   Didn’t want this insanity of shunts to face antiplatelets…  Probably right call.

The surest way to do this is with dual lumen balloon and Onyx (no Phil or Squid here yet).  18 is better than 34