Transarterial glue embolization using a balloon flow arrest technique for arteriovenous fistula

Treatment options for intracranial dural arteriovenous fistulas (DAVFs) include direct surgery, endovascular treatment, including transarterial and/or transvenous embolization, radiosurgery and combinations of these treatments4,7). To achieve a complete cure and to eliminate neurological complications, the arteriovenous shunt must be completely closed during every treatment procedure, and normal cerebral venous drainage must be preserved. Except for anterior cranial fossa, tentorial and craniocervical junction DAVFs, endovascular procedures, particularly transvenous embolization, have proven to be useful in treating many DAVFs, obliterating the fistula by sacrificing the affected sinus10). However, in patients harboring DAVFs with direct cortical venous drainage or for whom transvenous access is limited because of venous sinus thrombosis or obstruction, transvenous embolization may be impossible, and transarterial embolization must be considered9). Effective TAE of a DAVF requires penetration of a durable embolic agent into the fistulous connection with a preservation of normal venous drainage. Some authors emphasize techniques that involve wedging a microcatheter into the main feeding artery to inject a diluted mixture of N-butyl cyanoacrylate (NBCA) glue and iodized oil. Others also emphasize the importance of preparatory devascularization of other minor feeding arteries by embolization to avoid fragmentation of the glue column by competing inflows3,9). The wedge technique requires navigation to a sufficiently distal segment so that the diameter of the feeding artery must match that of the microcatheter tip. Such positioning of a microcatheter is not always possible in the large caliber, tortuous conduits that typically supply DAVFs. The Masamune catheter (Fuji Systems, Tokyo, Japan) is a Technical Note JNET 2:125-131, 2008