Embolization of cranial dural arteriovenous fistulae with ONYX: Indications, techniques, and outcomes

Long-term follow-up of transarterial balloon-assisted Onyx embolization for endovascular treatment of dural arteriovenous fistulas: A single-institution case series and literature review

OBJECTIVE

Dural arteriovenous fistulas (DAVFs)-specifically, symptomatic DAVFs with cortical venous reflux-are aggressive lesions with a poor prognosis. Intra-arterial endovascular closure is considered the optional treatment for DAVFs and is currently performed at several international centers. However, long-term outcomes remain unknown. This study investigated the long-term efficacy and safety of transarterial balloon-assisted Onyx embolization in the treatment of DAVFs.

METHODS

A total of 14 consecutive patients who underwent endovascular treatment for DAVFs were treated by balloon-assisted Onyx embolization. Additionally, we retrospectively reviewed all cases reported in the literature and compared the outcomes of patients treated with single- vs dual-lumen microcatheters.

RESULTS

The patients at our institution were followed-up for 114.57 ± 33.52 months. Embolization was performed by balloon-assisted Onyx injection via a single feeding artery. Complete occlusion was achieved in 13 cases and partial occlusion in 1 case. At the final follow-up, all patients were functionally independent (Modified Rankin Scale score of 0-2), with no recurrence. In our review of 70 published cases of DAVFs that underwent endovascular treatment by balloon-assisted Onyx embolization, single- and dual-lumen balloon catheters were used in 33 and 37 patients, respectively. In the former group, there was complete or near-complete occlusion in 32 cases and partial occlusion in 1 case; and in the latter, there was complete or near-complete occlusion in 35 cases and partial occlusion in 2 cases. There were no deaths following endovascular treatment.

CONCLUSION

Measurable and durable outcomes can be achieved by endovascular treatment of DAVFs with the transarterial balloon-assisted Onyx embolization technique, especially in cases with small, distal, and circuitous feeding arteries.

Outcomes After Onyx Embolization as Primary Treatment for Cranial Dural Arteriovenous Fistula in the Past Decade

RATIONALE AND OBJECTIVES

This retrospective single-center study aims to evaluate endovascular therapy (EVT) of cranial dural arteriovenous fistulas (dAVF) with ethylene vinyl alcohol (EVOH) copolymer (Onyx) regarding occlusion rates, complications, and recurrences.

MATERIAL AND METHODS

From January 2008 to April 2018, 75 patients with dAVF (41 men, 34 women; mean age 56 years) underwent EVT with the nonadhesive liquid embolic agent as primary treatment. Patient records and angiograms were reviewed for demographic data, symptoms, fistula type and size, number of EVTs, amount of embolic material, occlusion rates, and recurrences.

RESULTS

Seventy-five patients with dAVFs were primarily embolized with EVOH in 96 EVTs. According to the Merland-Cognard classification the majority of dAVFs treated were type 4 (42.7%), followed by type 2a (18.7%), type 2a+b (17.3%), type 1 (8%), type 2b (5.3%), type 3 (5.3%), and type 5 (2.7%). Complete occlusion (CO) of the dAVF was achieved in 45/75 (60%) of cases after a single EVT and in 58 (77%) patients after one or several EVTs. Seven patients (9%) required additional surgical therapy for CO. Successful treatment was achieved for 70/75 (93%) patients including 10 (13%) patients with residual dAVFs type 1-2a. Recurrence after CO occurred in one (1.3%) patient and four (5.3%) patients remained refractory to therapy with dAVFs type > 2a. Procedure-related permanent morbidity occurred in 4/75 (5.3%) patients.

CONCLUSION

For more than a decade transarterial EVOH embolization has established as the first-line treatment for cranial dAVFs with high cure rates and low rates of complications and recurrences. Additional neurosurgical therapy is rarely required for curative treatment.

Intraosseous Cannulation of a Calvarial Diploic Vein for Embolization of a Symptomatic Dural Arteriovenous Fistula: A Technical Case Report

BACKGROUND AND IMPORTANCE

Dural arteriovenous fistulas (DAVFs) may present unique challenges for treatment depending on the anatomy and pattern of venous drainage. If endovascular techniques are to be employed, the DAVF must be amenable to transvenous or transarterial therapy. When access of peripheral vasculature does not provide a straightforward path, less conventional options may be available. This case highlights a novel, technically simple, and effective approach for the treatment of a subset of DAVFs, with venous drainage through calvarial diploic veins, that would make endovascular treatment otherwise challenging or impossible.

CLINICAL PRESENTATION

We present a case of a 66-yr-old female patient who was diagnosed with a symptomatic DAVF located along the sphenoid ridge with a large intraosseous channel containing the draining vein of the fistula. This lesion was successfully treated with transcranial endovascular embolization via direct intraosseous cannulation of the calvarial diploic vein. This novel approach obviated the need for a full-thickness craniotomy, afforded only minimal bone loss, and preserved the integrity of the dura. A 3-mo follow-up angiogram confirmed complete cure of the DAVF with no residual arteriovenous shunt. At 20 mo postembolization, the patient was symptom free, with no reported neurologic deficits. Complete diagnostic work-up, treatment planning in a multidisciplinary environment, and a novel approach for endovascular embolization utilizing a hybrid operating suite played key roles in the successful implementation of this technique.

CONCLUSION

This is the first report of direct intraosseous cannulation of a calvarial diploic vein for successful transcranial endovascular embolization of a symptomatic DAVF.

Pial Artery Supply as an Anatomic Risk Factor for Ischemic Stroke in the Treatment of Intracranial Dural Arteriovenous Fistulas

BACKGROUND AND PURPOSE

Although intracranial dural arteriovenous fistulas are principally supplied by dural branches of the external carotid, internal carotid, and vertebral arteries, they can also be fed by pial arteries that supply the brain. We sought to determine the frequency of neurologic deficits following treatment of intracranial dural arteriovenous fistulas with and without pial artery supply.

MATERIALS AND METHODS

One hundred twenty-two consecutive patients who underwent treatment for intracranial dural arteriovenous fistulas at our hospital from 2008 to 2015 were retrospectively reviewed. Patient data were examined for posttreatment neurologic deficits; patients with such deficits were evaluated for imaging evidence of cerebral infarction. Data were analyzed with multivariable logistic regression.

RESULTS

Of 122 treated patients, 29 (23.8%) had dural arteriovenous fistulas with pial artery supply and 93 (76.2%) had dural arteriovenous fistulas without pial arterial supply. Of patients with pial artery supply, 4 (13.8%) had posttreatment neurologic deficits, compared with 2 patients (2.2%) without pial artery supply (P = .04). Imaging confirmed that 3 patients with pial artery supply (10.3%) had cerebral infarcts, compared with only 1 patient without pial artery supply (1.1%, P = .03). Increasing patient age was also positively associated with pial supply and treatment-related complications.

CONCLUSIONS

Patients with dural arteriovenous fistulas supplied by the pial arteries were more likely to experience posttreatment complications, including ischemic strokes, than patients with no pial artery supply. The approach to dural arteriovenous fistula treatment should be made on a case-by-case basis so that the risk of complications can be minimized.

Four-dimensional computed tomography angiographic evaluation of cranial dural arteriovenous fistula before and after embolization

PURPOSE

This study aimed to evaluate the usefulness of four-dimensional CTA before and after embolization treatment with ONYX-18 in eleven patients with cranial dural arteriovenous fistulas, and to compare the results with those of the reference standard DSA.

PATIENTS AND METHODS

Eleven patients with cranial dural arteriovenous fistulas detected on DSA underwent transarterial embolization with ONYX-18. Four-dimensional CTA was performed an average of 2 days before and 4 days after DSA. Four-dimensional CTA and DSA images were reviewed by two neuroradiologists for identification of feeding arteries and drainage veins and for determining treatment effects. Interobserver and intermodality agreement between four-dimensional CTA and DSA were assessed.

RESULTS

Forty-two feeding arteries were identified for 14 fistulas in the 11 patients. Of these, 36 (85.71%) were detected on four-dimensional CTA. After transarterial embolization, one patient got partly embolized, and the fistulas in the remaining 10 patients were completely occluded. The interobserver agreement for four-dimensional CTA and intermodality agreement between four-dimensional CTA and DSA were excellent (κ=1) for shunt location, identification of drainage veins, and fistula occlusion after treatment.

CONCLUSION

Four-dimensional CTA images are highly accurate when compared with DSA images both before and after transarterial embolization treatment. Four-dimensional CTA can be used for diagnosis as well as follow-up of cranial dural arteriovenous fistulas in clinical settings.

Mid and long term outcomes of dural arteriovenous fistula endovascular management with Onyx. Experience of a single tertiary center

INTRODUCTION

The natural history of intracranial dural arteriovenous fistulas (DAVFs) with cortical venous drainage is unfavorable, and treatment is recommended in most cases. Early reports have documented excellent initial clinical and radiographic outcomes after Onyx embolization of DAVFs but little evidence is available regarding the long term durability of this technique.

METHODS

We retrospectively reviewed a database of 63 DAVFs in 53 consecutive patients who underwent Onyx embolization of a DAVF between 2001 and 2012 at our institution. Cognard types I and III were seen most commonly.

RESULTS

A total of 72 Onyx embolization procedures were successfully completed during the study period, resulting in complete or near complete occlusion by the end of the study period in 58 (92.1%) DAVFs. For DAVFs in which complete or near complete obliteration was attained, stability of obliteration at 6, 12, 24, and 46 months was 100%, 95.4%, 93.8%, and 92.3%, respectively. DAVF recanalization/regrowth was discovered on delayed follow-up angiography in only five instances in which immediate post-embolization angiography revealed complete obliteration. Complications were seen in seven embolization procedures and included cranial nerve palsies (n=3), embolic infarcts (n=2), intraparenchymal hemorrhage (n=1), and unintentional stent deployment (n=1).

CONCLUSIONS

Early evidence has indicated that endovascular Onyx embolization is safe and effective at achieving an initial angiographic cure. Results of our series suggest that angiographic and clinical outcomes of Onyx embolization remain relatively stable at mid and long term follow-up.

Recurrence of "cured" dural arteriovenous fistulas after Onyx embolization

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.

Use of onyx for transarterial balloon-assisted embolization of traumatic carotid cavernous fistulas: a report of 23 cases

BACKGROUND AND PURPOSE

TCCFs are a common complication following craniofacial trauma and are usually treated by coils or detachable balloons. The use of the liquid embolic agent Onyx as the sole agent for the treatment of TCCFs has been rarely reported. Herein, we summarized the preliminary experience and effectiveness of treating TCCFs with Onyx in 23 patients.

MATERIALS AND METHODS

From the 36 type A CCFs treated in our department between September 2005 and March 2011, a total of 23 posttraumatic direct CCFs were treated by using Onyx only via transarterial approach.

RESULTS

Immediate postprocedural angiograms demonstrated complete occlusion in all patients. All the patients underwent a single procedure except 1 with bilateral TCCFs. Up to 24-month clinical and 3-month angiographic follow-ups revealed an ongoing complete occlusion without any complications.

CONCLUSIONS

In this series, the use of Onyx for the transarterial embolization of TCCFs was feasible and effective. Associated adverse events were rare.

Stereotactic radiosurgery of cranial arteriovenous malformations and dural arteriovenous fistulas

Cranial arteriovenous malformations (AVM) and cranial dural arteriovenous fistulas (AVF) carry a significant risk of morbidity and mortality when they hemorrhage. Current treatment options include surgery, embolization, radiosurgery, or a combination of these treatments. Radiosurgery is thought to reduce the risk hemorrhage in AVMs and AVFs by obliterating of the nidus of abnormal vasculature over the course of 2 to 3 years. Success in treating AVMs is variable depending on the volume of the lesion, the radiation dose, and the pattern of vascular supply and drainage. This article discusses the considerations for selecting radiosurgery as a treatment modality in patients who present with AVMs and AVFs.

Cavernous redirection of venous drainage after partial transvenous coil occlusion of a sigmoid sinus dAVF: coil mass retrieval with flexible cysto-urethroscopy grasping forceps. a technical note

We describe the case of a patient who presented with ocular symptoms (chemosis, proptosis, increased intra-ocular pressure, impaired visual acuity) eight months after the transvenous coil occlusion of an ipsilateral sigmoid sinus dural arteriovenous fistula (dAVF). Digital substraction angiography revealed a partial occlusion of the left sigmoid sinus with coils. Since the connection from the sigmoid sinus to the internal jugular vein was obliterated by coils without interrupting the arteriovenous shunt, the venous drainage was redirected into the inferior petrosal sinus, the cavernous sinus and the superior ophthalmic vein. The transjugular access to the inferior petrosal sinus was obstructed by a large coil mass in the jugular bulb. Several attempts to remove these coils with an Alligator retrieval device and a goose neck snare failed. The coil mass was withdrawn via a direct access to the internal jugular vein using flexible cysto-urethroscopy grasping forceps, an urological device designed for the removal of kidney stones. After establishing anterograde drainage, the now accessible inferior petrosal sinus was occluded with fibered coils and the dAVF was completely obliterated. The ocular symptoms resolved within ten days.