Double-lumen arterial balloon catheter technique for Onyx embolization of dural arteriovenous fistulas: initial experience

Abstract

Background: Dural arteriovenous fistulas are vascular malformations with variable clinical symptoms that range in severity from completely asymptomatic to seizures, dementia, loss of vision and intracranial hemorrhage. Historically, surgical obliteration was the treatment of choice but, more recently, endovascular embolization has become the first-line treatment. The liquid embolic agent Onyx (ethyl vinyl copolymer) has become the agent of choice, but problems with reflux around the delivery microcatheter and inadvertent venous penetration have arisen.

Methods and results: We present six cases in which the double-lumen balloon microcatheter was used to transarterially embolize dural arteriovenous fistulas via injection of Onyx through the wire lumen. Depending on the individual pathology a venous balloon was also used in some cases. The advantages and disadvantages of the use of these devices are discussed.

Conclusions: We consider that the use of the double-lumen balloon technique for fistula embolization has the potential for reducing overall procedural times, procedural failures and catheter retention in certain situations. In such cases we would advocate this as a first-line technique. When lower profile, more navigable balloon catheters become available, this may become the standard of care.

Keywords: Balloon; Fistula; Liquid Embolic Material; Technique; Vascular Malformation.

Figures

Figure 1

Lateral projection angiogram via the arterial balloon catheter within the right middle meningeal artery demonstrating the fistula.

Figure 2

Lateral projection angiogram via the arterial guide catheter demonstrating the filling defect of the venous balloon catheter within the right transverse sinus.

Figure 3

Non-subtracted lateral projection angiogram demonstrating the size and shape of the arterial balloon suggestive of rupture.

Figure 4

Townes projection angiogram from the right common carotid artery demonstrating the dural fistula with the venous varix which drained into the sagittal sinus and left transverse sinus.

Figure 5

Lateral projection angiogram with right external carotid injection demonstrating the deflated venous balloon within the superior sagittal sinus, Onyx cast and slow flow from a posterior branch of the middle meningeal artery due to downstream occlusion.

Figure 6

Lateral projection angiogram at completion of the procedure from the left internal carotid artery demonstrating preservation of the transverse sinus providing a drainage pathway for normal brain parenchyma.