Endovascular Treatment of Dural Arteriovenous Fistulas Using Transarterial Liquid Embolization in Combination with Transvenous Balloon-Assisted Protection of the Venous Sinus

Illustration of a representative case. A, Right external carotid artery angiogram shows a Cognard IIa+b/Borden II dAVF located at the transverse and sigmoid sinuses with multiple feeding arteries out of numerous vascular territories. B, Right internal carotid artery angiogram shows dural branches of the internal carotid artery feeding the fistula (black arrow). C, Venous phase of B. Note the proximity of the fistula point (black arrow in B) to the junction of the vein of Labbé and of the inferior temporal veins into the sinus (black arrow). For successful treatment of the dAVF, the fistula point should be embolized while simultaneously preserving these veins. D, Superselective angiogram without balloon inflation via the feeder that was selected for embolization, the mastoid branch of the occipital artery (microcatheter tip marked with an open arrow). There is drainage via the sinus (white arrows) and only slight filling of the adjacent feeders (black arrow). E, Lateral x-ray shows the inflated balloon. F, Superselective angiogram after balloon inflation (microcatheter tip marked with an open arrow). Due to the temporary occlusion of the sinus, which shows only minimal enhancement at the edge of the balloon (white arrow) at the junction of the vein of Labbé and the inferior temporal veins (C), nearby feeders show marked filling of contrast agent (black arrows). The angiograms with the inflated balloon serve as a test injection to estimate the distribution of the subsequently injected liquid embolic agent. G, Onyx cast after embolization with distribution of the embolic agent in all feeding artery territories. Common carotid artery angiogram of the arterial (H) and venous (I) phases 6 months after treatment shows complete occlusion of the fistula and patency of the venous sinuses and the normal superficial veins.