Transarterial Treatment of Cranial Dural Arteriovenous Fistulas: The Role of Transarterial and Transvenous Balloon-Assisted Embolization.

BACKGROUND AND PURPOSE: Treatment of dural arteriovenous fistulas can be performed by transarterial or transvenous accesses. For those fistulas located at a dural sinus wall, obliteration of the sinus might lead to a substantial risk of complications if the occluded sinus impairs normal venous drainage. For those fistulas with direct leptomeningeal venous drainage, navigation to reach the arteriovenous shunting point of a leptomeningeal vein is usually technically demanding. We report the outcomes of patients with dural AVFs treated by transarterial injection of liquid embolic agents assisted by transarterial double-lumen balloon catheters and/or transvenous balloon catheters. MATERIALS AND METHODS: This was a retrospective, 3-center study including patients with dural AVFs treated with a balloon-assisted technique in at least 1 treatment session. Angiographic follow-up was performed at 6 months. Clinical assessment was performed at admission and discharge and was reassessed at 30-day and 6-month follow-ups. RESULTS: Forty-one patients with 43 dural AVFs were treated. Thirty-four fistulas were located at a dural sinus wall. Treatment was performed using only a transarterial approach in 42 fistulas. Only 1 session was needed for complete obliteration of the fistula in 86% of the patients. Immediate complete angiographic occlusion was achieved in 39 fistulas. Of the 41 controlled fistulas, 40 (97.6%) were completely occluded at 6 months. Thirty-nine fistulas (95.1%) were cured without any report of major neurologic events or death during follow-up. CONCLUSIONS: Transarterial balloon-assisted treatment of dural AVFs with or without transvenous balloon protection was shown to be safe and effective.

A Novel Configuration of Pipeline Embolization Device for Internal Carotid Bifurcation Region Aneurysms: Horizontal Deployment.

PURPOSE: To describe a novel configuration of pipeline embolization device for internal carotid bifurcation region aneurysm, named horizontal stenting. CLINICAL PRESENTATION: A 64-year-old woman, with visual deficit, harboring a large wide-necked aneurysm located at the junction between left internal carotid artery and left A1 segment of anterior cerebral artery, was submitted to endovascular treatment. As she had pre-existing occlusion of left internal carotid, approach from the contralateral internal carotid was used to advance the pipeline embolization device through the anterior communicating artery and place the flow diverter horizontally across the neck (from M1 to A1). Coil embolization was also performed through a microcatheter navigated via posterior communicating artery. The intervention was uneventful, with total aneurysm occlusion. Patient presented with visual improvement on follow-up. CONCLUSION: Horizontal deployment of pipeline embolization device appears to be an acceptable and feasible alternative to treat internal carotid bifurcation aneurysms. Long-term follow-up and a greater number of cases are mandatory to establish the safety of this strategy.

Basilar Artery Fenestration Aneurysms: Endovascular Treatment Strategies Based on 3D Morphology.

PURPOSE: Basilar artery is the second most common site of fenestration, after the anterior communicating region. It is believed this variation predisposes a patient to posterior aneurysm formation and increases the complexity of the surgical anatomy. Endovascular management has become the first option to treat these aneurysms. We retrospectively evaluated eight patients, who underwent endovascular treatment for fenestrated basilar artery related aneurysms (fBA-AN). Additionally, based on our findings and on literature review, we developed a treatment strategy based on a proposed classification of fBA-AN. METHODS: Between June 2010 and September 2012, eight patients harboring nine basilar artery fenestration aneurysms were consecutively treated. Based on aneurysm morphology (neck size) and its relationship to the fenestration (sparing or not one channel) characterized by 3D-DSA, we proposed a simple classification and treatment strategies. Additionally, a literature review was performed. RESULTS: All patients received endovascular treatment. Most aneurysms involved the vertebrobasilar junction and both channels of the fenestration. A total of 5 aneurysms had wide neck while 4 had narrow neck. Overall, 5 (55.5 %) aneurysms were treated with stent assisted coiling, 3 (33.3 %) aneurysms with selective coiling, and 1 (11.1 %) aneurysm with balloon assisted coiling. We had only 1 (11.1 %) complication, named aneurysm rupture. CONCLUSION: Basilar artery fenestration aneurysms are rare and complex lesions. Endovascular treatment appears to be safe and efficient. The detailed understanding of the aneurysm morphology and its relation to the fenestration is strongly recommended to treatment planning. Further studies are necessary to validate the utility of the proposed classification and treatment strategy.

Endovascular treatment of isolated posterior inferior cerebellar artery dissecting aneurysms: parent artery occlusion or selective coiling?

PURPOSE: Isolated posterior inferior cerebellar artery dissecting aneurysms are rare lesions. Their underlying pathology, presentation, and natural history are poorly understood. Their treatment is controversial, and few data are available regarding the best treatment. We conducted the first study comparing selective coiling and parent artery occlusion for the treatment of isolated PICA dissecting aneurysms. METHODS: All patients harboring isolated PICA dissecting aneurysms treated between January 2006 and October 2012, in a single center, were retrospectively evaluated. Patients were consecutively submitted either to selective coiling or parent artery occlusion. The safety and durability (recanalization and rebleeding rates) of each treatment were established. In order to compare the results of both treatment modalities, we also performed a literature search of all cases of isolated PICA dissecting aneurysms endovascularly treated. RESULTS: Fourteen patients harboring isolated PICA dissecting aneurysms were assigned to endovascular treatment in our center (eight to selective coiling vs six to parent artery occlusion). There was no statistical difference between both groups regarding complications. No patient experienced rebleeding. One recanalization was observed in the selective coiling group. Based on literature review (83 cases), selective coiling and parent artery occlusion showed similar success rate in preventing rebleeding. Parent artery occlusion was significantly associated with a higher risk of ischemic complication (p = 0.013). CONCLUSIONS: Both selective coiling and parent artery occlusion are highly effective in preventing rebleeding in isolated PICA dissecting aneurysms. Although total complication rate is similar between both modalities, parent artery occlusion is significantly associated to a higher risk of ischemic events.

Splenic artery steal syndrome after liver transplantation: an alternative technique of embolization.

Arterial steal syndrome after orthotopic liver transplantation (OLT) is characterized by arterial hypoperfusion of the graft, which is caused by a shift in blood flow into the splenic or gastroduodenal arteries. It causes hepatic hypoperfusion with attendant clinical manifestations of elevated liver function enzymes, allograft dysfunction, and cholestasis. Left untreated, the condition has a significant potential risk for postoperative morbidity and graft loss. Herein we have reported the case of a 68-year-old woman who developed splenic artery steal syndrome (SASS) after deceased donor liver transplantation. She was diagnosed by duplex Doppler ultrasonography and celiac trunk angiography, and subsequently treated with splenic artery embolization.