Onyx Embolization of Dural Arteriovenous Fistula, using Scepter C Balloon Catheter: a Case Report
A 77-year-old man presented with gait disturbance that had persisted for 1 month. He had a history of dementia and depression for which he had received medication. Brain magnetic resonance imaging (MRI) revealed atrophy and venous congestion. Computed tomography (CT) angiography revealed DAVF of the superior sagittal sinus (SSS) (). Transfemoral cerebral angiography (TFCA) showed that the SSS DAVF was supplied via multiple branches of the external carotid artery (ECA), the right anterior cerebral arteries, and the meningeal branches of the internal carotid artery (ICA) and vertebral artery (). Anterograde drainage was not observed through the SSS, while drainage through the vein of Labbe and sphenoparietal sinus was main. TFCA revealed venous hypertension and galenic venous drainage. Furthermore, TFCA showed CVR (). The DAVF was large and complex. According to Borden classification, the DAVF was type 2.\nEmbolization of DAVF was performed under general anesthesia using a biplanar fluoroscopic unit. Right femoral artery and left femoral vein were punctured with an angiography needle (18 gauge). A 6Fr Envoy guiding catheter (Codman, Miami Lakes, Florida, USA) was then introduced to the right ECA. Another Envoy catheter was introduced to the right internal jugular vein through the venous root. Heparin was administered in order to achieve a targeted activated coagulation time of 250-300s throughout the procedure. Using a transvenous approach, a microcatheter (Echelon 10) was placed at the fistulous sac of the SSS (). Eleven coils (GDC 360 Standard 24 mm × 40 cm (×7), 22 mm × 40 cm (×3), 20 mm × 33 cm (×1)) were inserted through the microcatheter (Echelon 10). Another microcatheter (Prowler Select 18) was subsequently used to insert non-detachable coils; this was placed using Synchro 14 microwire. Other coils (Interlock Coil 14 mm × 30 cm (×2), 14 mm × 20 cm (×1), 12 mm × 30 cm (×1), 12mm × 20 cm (×1), Nester Coil 10 mm × 14 cm (×2), 6 mm × 14 cm (×3), 4 mm × 14 cm (×3)) were inserted through this microcatheter. Following intravenous coil embolization using various coils, DAVF was occluded partially. Angiography revealed that retrograde drainage through the fistula remained (). A Scepter C balloon catheter (4×15 mm) was placed at the most distal segment of the middle meningeal artery (MMA). The tip of the balloon microcatheter was positioned at the DAVF. After that, balloon inflation and deflation was successfully carried out. () In order to occlude any residual fistula, Onyx18 was then injected through the dual lumen balloon catheter positioned in the MMA. Over a period of 22 minutes, a total of 4.5 cc of Onyx18 was injected, after which the DAVF was almost completely occluded (). Following embolization, angiography revealed no arteriovenous shunting or CVR (). The balloon was deflated by syringe suction without difficulty. The catheter was then immediately removed without any noticeable adherence to the Onyx cast. Procedure related complications were not observed. The patient symptoms were unchanged during hospitalization.