Combined surgical and endovascular approach to a complex dural arteriovenous fistula involving the superior sagittal sinus and torcula.
A complex dural arteriovenous fistula (dAVF) may require complex treatment strategies to achieve successful obliteration. We describe a combined open surgical and endovascular approach to a dAVF involving the superior sagittal sinus (SS) and torcula. A 68-year-old male with Factor V Leiden mutation presented with altered mental status from venous hypertension secondary to a complex, high-flow Borden III dAVF with internal carotid and bilateral external carotid artery feeders draining into the SS and torcula. Because the venous channel to the recipient SS at the point of convergence of the AV shunting was not accessible transfemorally due to venous stenosis, a surgical strategy using a midline burrhole for direct catheterization of the SS was devised. A balloon was inflated in the sinus during arterial embolization. This technique was effective in achieving embolization of multiple arterial feeders via a single vessel injection. Covered Atrium iCasts were introduced in a telescoping fashion after angioplasty of the posterior SS-torcular junction in an attempt to functionally occlude further AV shunting. Postembolization angiography revealed greatly diminished AV shunting with improved intracranial transit time and retrograde cortical venous drainage. The patient was maintained on anticoagulation and made a complete recovery following the intervention; however, he subsequently deteriorated acutely, and died on postprocedure day 4. This case illustrates the difficulties associated with treating a complex AVF, describes a temporizing solution, and reports a potential complication from placing a covered stent in the SS.
Spiotta
Alejandro M
AM
The Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA.
Sivapatham
Thinesh
T
Hussain
Muhammad Shazam
MS
Hui
Ferdinand K
FK
Moskowitz
Shaye I
SI
Gupta
Rishi
R
D000368:Aged; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D003131:Combined Modality Therapy / Q000295:instrumentation / Q000379:methods; D057510:Endovascular Procedures / Q000379:methods*; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D011859:Radiography; D054063:Superior Sagittal Sinus / Q000000981:diagnostic imaging / Q000601:surgery*; D054064:Transverse Sinuses / Q000000981:diagnostic imaging / Q000601:surgery*; D017211:Treatment Failure; D014656:Vascular Surgical Procedures / Q000379:methods*