Limitations and technical considerations of endovascular treatment in neonates with high-flow arteriovenous shunts presenting with congestive heart failure: report of two cases

Abstract

Even in neonates, endovascular treatment is the procedure of choice for high-flow AV shunts presenting with progressive congestive heart failure resistant to medical management. We discuss limitations and technical considerations of endovascular treatments in small neonates with high-flow AV shunts and congestive heart failure.

Endovascular Management in Children with Vein of Galen Aneurysmal Malformation

“…Some authors navigate a microcatheter directly into feeding arteries without a guiding catheter to avoid complications to the femoral artery. A supple microcatheter with rigid proximal parts facilitates better control and better navigability in the vessels, especially in a small premature neonate [14] . Usually a couple of embolizations are done in one session.…”

Endovascular Management of Pediatric High-Flow Vertebro-Vertebral Fistula with Reversed Basilar Artery Flow

“…Although 30% of patients are symptom-free at the time of diagnosis, a pulsatile bruit over the neck with tinnitus comprise the most common findings in patients with VAVFs 16 .Congenital or spontaneous highflow VAVFs can be associated with steal phenomenon and vertebrobasilar insufficiency resulting in transient ischemic attacks of diplopia, vertigo, and ataxia 16,17 . Cardiac decompensation leading to high-output congestive heart failure resulting from high-flow VAVF is more common in the congenital and pediatric population 2,6,14,18 . Additionally, as a subtype of spinal extradural AVF, VAVFs may cause local mass effect with radiculopathy, venous congestion with spinal cord/medullary ischemia, or subarachnoid hemorrhage particularly in adults.…”

Lower vertebral-epidural spinal arteriovenous fistulas: a unique subtype of vertebrovertebral arteriovenous fistula, treatable with coil and Penumbra Occlusion Device embolization

“…The term VVAVF has been broadly used to characterize extradural AVFs in which the arteriovenous shunt occurs between the vertebral artery and any adjacent venous structure, including jugular,7 suboccipital,8 paraspinal,9 and epidural veins 3. When epidural venous drainage is present, more often than not, it occurs indirectly via retrograde drainage from the primary paraspinal venous drainage of the fistula.…”

“…Considering all VVAVF, the most common presenting sign of a vertebral-epidural spinal AVF is an objective bruit,13 with other recognized clinical presentations including radiculopathy due to local mass effect from epidural venous compression,14 myelopathy related to retrograde intradural venous drainage/congestion,15 subarachnoid or epidural hemorrhage,16 high-output congestive heart failure,9 and vertebrobasilar insufficiency secondary to arterial steal 17. The natural history of direct lower vertebral-to-epidural single-hole AVF is unknown, though given the presence of very high flow into a capacious venous collector, the eventual development of high-output cardiac failure would not be unexpected.…”