Two Microcatheter Technique for Embolization of Arteriovenous Fistula with Liquid Embolic Agent
A 53-year-old man presented with pain in the neck, both shoulders, and in the upper extremities. A vertebral angiogram showed SDAVF at the level of C1, supplied by the left C1 segmental artery and draining into the perimedullary and perimesencephalic veins (). Under general anesthesia a 6F guide catheter was placed into the left vertebral artery. At first, we considered two flow-control strategies: (1) temporary vertebral artery occlusion by a balloon placed at the origin of the C1 feeder; and (2) temporary balloon occlusion by a small balloon catheter placed in the C1 feeder. However, it was not possible to use either of these techniques because the VA at the curved angle was not fitted by a 4- or 5-mm compliant balloon and a small balloon catheter could not be introduced into the C1 feeder. Finally we decided to use the two catheter technique.\nTwo microcatheters were introduced into the site of the AVF and were positioned with approximately a 5-mm tip distance between them. A repeat angiogram of the glue embolization microcatheter indicated a significant decrease of the AVF flow after a 1.5-mm × 6-cm coil was introduced without detachment into the feeding artery. After obtaining a selected angiogram of C1 artery to make sure that the glue embolization was safe, a 33% glue lipiodol mixture was infused into the AVF. The reflux of the glue filled only a portion of the area between the AVF and the coil which allowed the glue to have good penetration into the vein through the AVF. When the glue embolization was finished, the control angiogram using the guiding catheter showed complete occlusion of the AVF. The coil was then detached and the coil embolization microcatheter was retrieved ().