title: Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula.
abstract: BACKGROUND
  Some complex dural arteriovenous fistulas (DAVFs) are lesions that typically have numerous arterial feeders. Surgery, including resection of fistulas or skeletonization of the diseased sinus, is still one of the important treatments for these lesions. However, major blood loss is usually encountered during craniotomy because of abundant arterial feeders from the scalp and transosseous vessels. We present a novel approach for obliteration of the fistulas with less blood loss.
  
  
  METHODS
  Our first case was a 52-year-old male who suffered from syncope and seizure. Cerebral digital subtraction angiography (DSA) revealed complex DAVFs with numerous arterial feeders from bilateral external carotid arteries (ECAs) and drainage into the superior sagittal sinus with cerebral venous reflux. The second case was a 48-year-old male presenting with chronic headache. His DSA also showed complex DAVFs along the superior sagittal sinus with cerebral venous reflux. In both cases, we performed the surgical procedure to obliterate the pathological fistulas after temporary clamping of bilateral ECAs and noted less blood loss than in the conventional surgery.
  
  
  RESULTS
  The follow-up DSA showed successful obliteration of the complex DAVFs on the first case and partial improvement on the second case followed by transarterial embolization (TAE). The symptoms of the both patients were relieved after surgery with good recovery.
  
  
  CONCLUSIONS
  Temporary clamping of bilateral ECAs can improve the safety and ease the surgical excision for complex DAVFs. By using this technique, neurosurgeons can deal with aggressive DAVFs more confidently and calmly.
authors.affiliation: Department of Surgery, Tri-Service General Hospital Songshan Branch, Taipei, Taiwan.
authors.forename: Shih-Chieh
authors.initials: SC
authors.lastname: Shen
authors.affiliation: Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan.
authors.forename: Wen-Hsieh
authors.initials: WH
authors.lastname: Chen
authors.affiliation: Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan.
authors.forename: Se-Yi
authors.initials: SY
authors.lastname: Chen
authors.affiliation: Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan.
authors.forename: Ming-Hsi
authors.initials: MH
authors.lastname: Sun
authors.affiliation: Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan.
authors.forename: Chiung-Chyi
authors.initials: CC
authors.lastname: Shen
authors.affiliation: Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan.
authors.forename: Yuang-Seng
authors.initials: YS
authors.lastname: Tsuei
keywords: Dural arteriovenous fistula; external carotid arteries; temporary clamping