Micro-balloon-assisted embolization of anterior cranial fossa dural arteriovenous fistula via a trans-ophthalmic approach — a technical report and case series

Abstract

Purpose Dural arteriovenous fistulas (dAVF) account for approximately 10–15% of all intracranial arteriovenous abnormalities. dAVFs carry a significant risk of mortality, particularly in cases of acute hemorrhage, of up to 10%. A small proportion of these dAVFs are found in the anterior cranial fossa (ACF), of which the rate of hemorrhage can be as high as up to 91%. The Scepter Mini (SM) is the smallest dual-lumen micro-balloon (MB) available for neurointerventional practice. It consists of a 2.8 French outer diameter, with a 2.2 mm × 9 mm semi-compliant balloon providing a working length of 165 cm. The SM is navigated with a 0.008-inch wire making it a particularly attractive tool accessible to the pedicles normally reached with liquid embolization micro-catheters. Methods Five consecutive patients over a 1-year period between 2020 and 2021 were evaluated and treated for ACF dAVF using a liquid embolization approach using the SM balloon. All patients were treated using ethylene–vinyl alcohol copolymer (EVOH), of which Squid 18 and/or Squid 12 were the chosen viscosities. Control angiograms were performed for all patients post-embolization. Results All patients demonstrated complete occlusion of the ACF dAVF on immediate post-treatment angiography. No immediate complications were encountered; particularly, there were no reports of visual field deficit in any of the patients. Conclusion The MB is a valuable adjunctive tool that can enhance the safety and efficacy of trans-ophthalmic embolization of ACF dAVFs, providing additional protection to the retinal and posterior ciliary arteries against unwanted reflux of liquid embolic agent.

Balloon-Assisted Coil Embolization and Balloon Angioplasty for Post Subarachnoid Hemorrhage Vasospasm: Initial Experience with Scepter Mini Balloon

“…In the first case, the available literature suggests that the catheters perform well with a high degree of technical success. 8,9 A study also supports its use for distal AVF in tortuous and small arterial feeders, especially in the pediatric population, where vessel diameters may be as small as 0.65 mm. 10 The versatility of the catheter and its different applications are also reported in another study, indicating 4 distinct uses: AVF embolization, balloon-occlusion with simultaneous embolization via a second microcatheter, diagnostic angiography with simultaneous balloon obstruction for flow control, and navigation support.…”

“…Due to its relatively recent release, the SMB has been mainly reported in scarce case reports and series, mostly involving patients treated with AVM embolization, while only a few articles report data regarding its use in the treatment of intracranial aneurysms. In the first case, the available literature suggests that the catheters perform well with a high degree of technical success [ 8 , 9 ]. A study also supports its use for distal AVF in tortuous and small arterial feeders, especially in the pediatric population, where vessel diameters may be as small as 0.65 mm [ 10 ].…”

Microsurgical versus endovascular treatment of ethmoidal dural arteriovenous fistulas: systematic review and meta-analysis with a single-center case series

“…Recently, the advent of dual-lumen microballoon and microcatheter technologies, with their sufficient navigability and trackability, has facilitated endovascular catheterization in small, tortuous arterial branches, such as those seen with ethmoidal DAVFs. 12,16,17 Furthermore, this novel microballoon has demonstrated flow arrest in some small, single-center series, allowing for preservation of the ophthalmic artery and thus vision, which has historically precluded the use of EVT for lesions in challenging areas, such as ethmoidal DAVFs. 12,16,17 While EVT aims to obviate the perioperative risks of surgical disconnection and bleeding, there is conflicting evidence regarding the safety and efficacy of EVT when compared with surgical approaches.…”

“…12,16,17 Furthermore, this novel microballoon has demonstrated flow arrest in some small, single-center series, allowing for preservation of the ophthalmic artery and thus vision, which has historically precluded the use of EVT for lesions in challenging areas, such as ethmoidal DAVFs. 12,16,17 While EVT aims to obviate the perioperative risks of surgical disconnection and bleeding, there is conflicting evidence regarding the safety and efficacy of EVT when compared with surgical approaches. 5 The main deterrents of endovascular management of ethmoidal DAVFs are the risk of blindness caused by inadvertent embolization of the central retinal artery, the risk of systemic diffusion of the embolic agents, and the need to navigate small-caliber vessels.…”

“…5,10,11 Advances in transarterial embolization (TAE) and transvenous embolization (TVE), including advances in the embolysates used, such as Onyx and nbutyl-2-cyanoacrylate (NBCA), as well as the introduction of novel microballoons and microcatheters, have been instrumental in the improved DAVF obliteration rates seen with endovascular treatment (EVT) in recent years, attributing to the growing popularity of these techniques. [12][13][14][15][16][17][18] While the popularity of these approaches has undoubtedly increased, it is unknown whether patient outcomes, including fistula obliteration and complication rates, rates of DAVF recurrence, and postoperative modified Rankin Scale (mRS) score, vary significantly from those achieved with microsurgical DAVF obliteration. This paper presents four patients with ethmoidal DAVFs treated surgically by one surgeon at a single institution, as well as a systematic review and meta-analysis of the literature, which sought to compare surgical and endovascular approaches for ethmoidal DAVFs.…”