Recurrence of "cured" dural arteriovenous fistulas after Onyx embolization

Abstract

Endovascular embolization with Onyx has been increasingly used to treat intracranial and spinal dural arteriovenous fistulas (DAVFs). Several case series have been published in recent years reporting high DAVF cure rates with this technique. Although it is seldom reported, DAVF recurrence may occur despite initial "cure." The authors present 3 separate cases of a recurrent DAVF after successful transarterial Onyx embolization. Despite adequate Onyx penetration into the fistula and draining vein, these cases demonstrate that DAVF recanalization may reappear with filling from previous or newly recruited arterial feeders. Other published reports of DAVF recurrence are examined, and potential contributory factors are discussed. These cases highlight the need for awareness of this possible phenomenon and suggest that follow-up angiography should be considered in patients treated with catheter embolization.

Figures

Fig. 1. Case 1

A: Right external carotid artery (ECA) angiogram (lateral projection) demonstrating a DAVF (arrow) supplied by branches of the right middle meningeal and superficial temporal arteries with venous drainage via an ectatic cortical vein with multiple varices. B: Right internal carotid artery angiogram (lateral projection) in venous phase demonstrating abnormal delayed filling of the superior sagittal sinus due to partial thrombosis. C: Right ECA angiogram (lateral projection) after transarterial Onyx embolization demonstrating complete DAVF occlusion with no evidence of early venous drainage. D: Multiple axial head CT slices obtained after embolization, revealing the presence of Onyx cast material (arrows) within the draining cortical vein. E: Repeat right ECA angiogram (lateral projection) demonstrating DAVF recurrence (arrow). F: Final right ECA angiogram (lateral projection) showing complete DAVF obliteration after repeat transarterial Onyx embolization.

Fig. 2. Case 2

A: Left ECA angiogram (anteroposterior projection) demonstrating a DAVF (arrow) supplied by the left middle meningeal artery with venous drainage into the left superficial middle cerebral vein and vein of Labbé. B: Left ECA angiogram (anterior oblique projection) after transarterial Onyx embolization revealing occlusion of the fistula without early venous drainage. C: Selective microcatheter injection into a left middle meningeal pedicle revealing DAVF recanalization (arrow) with venous drainage into the left superficial middle cerebral vein. D: Left ECA angiogram (anterior oblique projection) obtained after repeat embolization, demonstrating DAVF occlusion. E: Left internal carotid artery angiogram (anteroposterior projection) revealing recruitment of new arterial feeders to the DAVF (arrow) via small ethmoidal branches of the left ophthalmic artery.

Fig. 3. Case 3

A and B: Left L-3 segmental artery injection on spinal angiography (anteroposterior projection) in early arterial (A) and late arterial (B) phases revealing a DAVF fed by a radicular branch at this level (single arrow) with drainage into a slow flowing vein (double arrows). C and D: Left L-2 segmental artery injection on spinal angiography (anteroposterior projection) in early arterial (C) and late arterial (D) phases, demonstrating DAVF recurrence from a collateralized radicular branch under the L-3 pedicle with similar drainage into a slow flowing vein (double arrows). E: Visual inspection during surgical ligation revealing the presence of Onyx cast material within the draining vein (arrow) of the fistula.