- Email: [email protected]
Transarterial Onyx Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist—Initial U.S. Experience with Copernic RC Venous Remodeling Balloon
Accepted Manuscript ® Transarterial Onyx Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist - Initial US Experience with the Copernic RC Venous Remodeling Balloon Abdulrahman Alturki, MBBS, MSc, FRCSC, Alejandro Enriquez-Marulanda, M.D., Philip Schmalz, M.D., Christopher S. Ogilvy, M.D., Ajith J. Thomas, M.D. PII:
S1878-8750(17)31811-9
DOI:
10.1016/j.wneu.2017.10.083
Reference:
WNEU 6736
To appear in:
World Neurosurgery
Received Date: 13 September 2017 Revised Date:
13 October 2017
Accepted Date: 14 October 2017
Please cite this article as: Alturki A, Enriquez-Marulanda A, Schmalz P, Ogilvy CS, Thomas AJ, ® Transarterial Onyx Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist - Initial US Experience with the Copernic RC Venous Remodeling Balloon, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.10.083. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Transarterial Onyx® Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist -- Initial US Experience with the Copernic RC Venous Remodeling Balloon
5
Abdulrahman Alturki, MBBS, MSc, FRCSC1,2 *, Alejandro Enriquez-Marulanda, M.D.1 *, Philip
6
Schmalz M.D.1,3, Christopher S. Ogilvy, M.D.1, Ajith J. Thomas, M.D. 1
7
RI PT
1 2 3 4
1
Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,
MA, USA 2Department of Neurosurgery, The National Neuroscience Institute, King Fahad Medical
9
City, Riyadh, Saudi Arabia. 3Department of Neurosurgery, University of Alabama, Birmingham,
10
AL, USA.
11
*These authors contributed equally to this study.
12
Keywords: Dural arteriovenous fistulas; Therapeutic embolization; balloon-assisted technique;
13
sinus protection; Meningeal arteries; Intracranial pressure; Balloon occlusion; Dimethyl sulfoxide;
14
Tantalum
15
Running Head: Balloon-assisted protection during Onyx embolization.
16
Corresponding Author
17
Ajith J. Thomas, M.D.
18
Neurosurgical Service
19
Beth Israel Deaconess Medical Center
20
Harvard Medical School
21
110 Francis Street
22
Boston, MA, 02215
23
Email: [email protected]
24
Phone: 617-632-9785
25
AC C
EP
TE D
M AN U
SC
8
Introduction
®
ACCEPTED MANUSCRIPT
Dural-Arterio-venous-fistulas(DAVFs) consists of anomalous connections between
27
branches of dural arteries to dural venous sinuses, dural veins, meningeal veins or cortical
28
veins1. These vascular lesions account for approximately 15% of arteriovenous
29
malformation and most commonly involve the transverse and the sigmoid sinus2–4. DAVFs
30
can be asymptomatic but also can be associated with either intracranial hemorrhage
31
(especially when there is cortical venous drainage and cortical reflux), venous hypertension
32
and non-hemorrhagic neurologic deficits1–3.
33
Treatment options for DAVF include observation, microsurgery, stereotactic radiosurgery,
34
vascular embolization or a combination of these modalities4–6. Currently, the mainstay of
35
treatment for DAVFs involves endovascular approaches, especially for high-grade lesions
36
that are associated with higher risks of complications1. Low-grade lesions may be
37
considered for endovascular treatment if associated with bothersome symptoms, such as
38
intractable tinnitus or headaches.
39
Transarterial embolization with preservation of the venous sinus has become the preferred
40
approach due to the development of newer liquid embolic agents such as Onyx®(ev3
41
Endovascular, Plymouth, MN)7. Onyx® is a non-adhesive agent that polymerizes gradually
42
in contact with blood that allows controllable penetration, high occlusion rates and low
43
procedure-related complications8. Because of its ability to enter small vessels, it is
44
important to be attentive to progression and migration of Onyx®, especially when
45
potentially dangerous anastomoses are present8. Two significant drawbacks with Onyx® are
46
the possibility of arterial reflux alongside the delivery microcatheter and inadvertent venous
47
penetration beyond the venous side of the fistula, even compromising the lumen of the
48
venous sinuses9.
AC C
EP
TE D
M AN U
SC
RI PT
26
ACCEPTED MANUSCRIPT
For further precision and avoidance of venous sinus compromise and sacrifice during
50
embolization, the use of a temporary balloon occlusion to protect the patency of dural
51
sinuses from embolic agents migration have been described in few publications outside the
52
US4,4–7,9–13. Here we present a case of bilateral symptomatic Borden Type II and Cognard
53
type IIB DAVF treated successfully with transarterial Onyx® embolization with
54
transvenous balloon protection of the sinus. This case is the first reported use of the
55
Copernic® RC balloon(BALT Extrusion, Montmorency, France) in the United States under
56
the “compassionate use” guidelines of the FDA.
M AN U
SC
RI PT
49
Materials and methods
57
Case description
59
A 64-year-old man, with past medical history of hypertension, dyslipidemia, renal cell
60
carcinoma(in remission) and a former smoker, presented with bilateral pulsatile tinnitus and
61
visual decline.
62
On exam, he was found to have bilateral papilledema. Radiologic evaluation consisting of
63
an MRI and MRA of the brain and a diagnostic cerebral angiogram demonstrated a
64
complex bilateral type 2 dural arteriovenous fistula with feeding vessels from bilateral
65
occipital and middle meningeal, left ascending cervical, bilateral marginal tentorial arteries,
66
and posterior meningeal branch of the right vertebral artery(Figure 1). Retrograde venous
67
reflux through the superior sagittal sinus was noted. The principal venous drainage from
68
the brain was through enlarged scalp and superficial veins rather than the dural venous
69
sinuses, indicating venous hypertension.
AC C
EP
TE D
58
ACCEPTED MANUSCRIPT
After multidisciplinary team discussion and review of available literature, treatment was
71
offered. Surgical strategy consisted of transarterial Onyx® embolization with venous sinus
72
balloon-assisted protection technique since both transverse sinus and sagittal sinus was
73
involved in drainage of the fistula.
74
Following IRB approval, we obtained "compassionate use" FDA approval of the Copernic®
75
RC balloon for one time use to repair this DAVF.
76
Endovascular treatment technique
77
Treatment was carried out endovascularly under general anesthesia in a staged fashion. The
78
second session was delayed one week to observe for deficits and allow for patient recovery.
79
Via transfemoral arterial access, the right posterior division of the middle meningeal
80
artery(MMA)
81
microcatheter(MicroVention, Tustin, CA, USA) through a 6F Benchmark(Penumbra,
82
Alameda, CA) guiding catheter in the ECA. Transfemoral venous access was also
83
established and the Copernic® RC 10x80mm balloon was positioned in the right transverse-
84
sigmoid sinus across the torcula into the left transverse sinus. The balloon was inflated
85
during embolization to protect the right transverse sigmoid venous sinus system and
86
torcula(Figure 2). After creating satisfactory cast in the MMA distribution, the balloon was
87
pulled back into the right transverse sigmoid sinus and catheterization of the right occipital
88
artery with a double lumen Scepter XC 4x11mm balloon(MicroVention, Tustin, CA, USA)
89
was performed(Figure 3). Onyx® was then delivered through the working lumen of the
90
inflated arterial balloon until distal penetration was judged sufficient with the Copernic®
91
RC balloon inflated during the embolization session. There was a venous pouch in parallel
SC
M AN U
selectively
catheterized
with
a
Headway®
Duo
167cm
AC C
EP
TE D
was
RI PT
70
ACCEPTED MANUSCRIPT
to the sigmoid sinus which had fistulous communications from the ascending pharyngeal
93
artery which drained into the jugular vein(Figure 3B). This anatomical variant has been
94
described in previous studies14. We elected not to embolize this component since the risk of
95
cranial nerve deficit would have been high.
96
The patient was observed overnight and after an unremarkable hospital course, was
97
discharged on postoperative day one.
98
In the second stage, the Copernic® RC 10x80mm balloon was positioned in the left
99
sigmoid-transverse system through the right internal jugular vein due to difficult left sided
100
venous access to the dural sinuses. The balloon was again inflated to protect the left
101
transverse sigmoid venous sinus system and torcula during embolization. The left occipital
102
artery was catheterized with a double lumen Scepter XC 4x11mm.
103
Complete obliteration of the left DAVF was achieved and patency of the left transverse and
104
sigmoid sinuses was preserved(Figure 4B&C).
105
sigmoid sinus was also conserved post-procedure(Figure 4A&C). The patient recovered
106
overnight without signs of neurologic deficit and was again released on postoperative day
107
one.
SC
M AN U
TE D
EP
AC C
108
RI PT
92
Patency of the right transverse and
Discussion
109
Previous approaches to endovascular treatment of DAVFs involved venous occlusive
110
strategies such as coil embolization of the involved dural venous sinus. This deconstructive
111
approach risks worsening venous hypertension due to inadequate cerebral venous drainage,
112
particularly in the setting of inadequate contralateral venous sinus drainage4,5. The strategy
ACCEPTED MANUSCRIPT
of venous sinus occlusion may also cause new lesion formation due to compromised
114
venous drainage.5,15
115
With improved endovascular devices, approaches which preserve venous drainage have
116
been advocated4. Transvenous balloon-assisted transarterial Onyx® embolization for
117
DAVFs was first described by Shi et al. in 200911. This case demonstrated safe occlusion of
118
DAVF via transarterial means with preservation of the venous sinuses using transvenous
119
balloons.
120
Transvenous balloon occlusion facilitates embolization by both protecting the patency of
121
the venous sinus as well as allowing liquid embolic infiltration into otherwise inaccessible
122
meningeal vessels contributing to the fistula.6,9,11. This technique may also decrease the
123
number of embolization sessions and improve the chance of anatomical cure11.
124
Additionally, transvenous balloon assistance can reduce the amount of embolic agent
125
required.6.
126
The Copernic® RC Venous Remodeling Balloon, was selected for this case. This is a low-
127
pressure, compliant hydrophilic balloon. The balloon is DMSO-compatible and has a
128
diameter of up to 10x80mm6. Designed for use with a 6F guide catheter and is designed for
129
use with the Trascend 0.014 microwire(Boston scientific, Miami, FL); though in this case a
130
Synchro2 Standard wire was used without difficulty. Reports using other devices have
131
shown incomplete sinus occlusion and consequent off-target embolization5.
132
The MMA has been described as the gateway for successful embolization of these
133
lesions.3,5,13 Transverse sinus DAVFs are commonly fed by branches from the middle and
134
posterior meningeal artery, by meningeal branches from the ascending pharyngeal artery,
AC C
EP
TE D
M AN U
SC
RI PT
113
ACCEPTED MANUSCRIPT
and by transosseous branches of the occipital artery or, more rarely, of the superficial
136
temporal artery10. It is essential that meticulous fluoroscopic monitoring during Onyx®
137
injection is performed to be aware of any possible reflux or migration of the embolic
138
agent11. Also, for further reduction of the risk of migration into the parent artery, the use of
139
a transarterial dual-lumen complement balloon poses the advantage that the inflation of the
140
balloon in the feeder vessels avoids the need of a proximal Onyx® plug to prevent the
141
reflux9,10, giving an additional safeguard during the procedure.
142
One of the major concerns of transvenous balloon-assisted-technique is the pressure
143
changes within the intracranial venous drainage when the balloon is inflated, which might
144
cause intracranial hypertension or venous territory infarctions6. A balloon inflation test may
145
be performed before embolization to assess venous compromise4,6. In cases of embolization
146
involving a dominant venous sinus the balloon may be periodically deflated to reduce the
147
risk of venous infarction4,6. Systemic heparinization should also be considered to minimize
148
the risk of thrombosis of the dural sinus6.
149
Risk of Onyx migration to a parallel venous channel is also possible when it is not
150
adequately protected by the venous balloon.
151
described a case in which migration of Onyx was evidenced in a patient with a Borden type
152
II fistula into the proximal vein of Labbé despite the use of venous balloon protection. The
153
intervention, however, was stopped timely and no impairment of the patency of the vein
154
was noted13. In our case there was evidence of a parallel venous channel of the right
155
sigmoid sinus which had fistulous communications from the ascending pharyngeal artery
156
which drained into the jugular vein. We elected to not embolize this component due to the
157
risk of cranial nerve deficit.
In the series of Piechowiak et al. they
AC C
EP
TE D
M AN U
SC
RI PT
135
ACCEPTED MANUSCRIPT
Conclusions
159
Transvenous and transarterial balloon-assisted transarterial Onyx® embolization is
160
becoming a useful treatment alternative in selected cases of DAVFs. Previous reports in
161
Asia and Europe with venous remodeling balloons are encouraging. We report the first
162
known experience with this device in USA. The device performed as expected and there
163
were no complications attributable to the device. Additionally, it provided a valuable
164
adjunct to improve the safety and efficacy of transarterial embolization. References
M AN U
165
SC
RI PT
158
1.
Gandhi D, Chen J, Pearl M, Huang J, Gemmete JJ, Kathuria S. Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment. AJNR Am J Neuroradiol. 2012;33(6):1007-1013. doi:10.3174/ajnr.A2798.
169 170 171
2.
Kwon BJ, Han MH, Kang H-S, Chang K-H. MR imaging findings of intracranial dural arteriovenous fistulas: relations with venous drainage patterns. AJNR Am J Neuroradiol. 2005;26(10):2500-2507.
172 173 174
3.
Griessenauer CJ, He L, Salem M, Chua MH, Ogilvy CS, Thomas AJ. Middle meningeal artery: Gateway for effective transarterial Onyx embolization of dural arteriovenous fistulas. Clin Anat N Y N. 2016;29(6):718-728. doi:10.1002/ca.22733.
175 176 177 178
4.
Choi BJ, Lee TH, Kim CW, Choi CH. Reconstructive treatment using a stent graft for a dural arteriovenous fistula of the transverse sinus in the case of hypoplasia of the contralateral venous sinuses: technical case report. Neurosurgery. 2009;65(5):E994996; discussion E996. doi:10.1227/01.NEU.0000351772.45417.92.
179 180 181 182
5.
Zhang Y, Li Q, Huang Q-H. Embolization of a superior sagittal sinus dural arteriovenous fistula under intrasinus balloon protection: A case report. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci. 2015;21(1):94-100. doi:10.1177/INR-2014-10098.
183 184 185
6.
186 187 188
7.
AC C
EP
TE D
166 167 168
Jittapiromsak P, Ikka L, Benachour N, Spelle L, Moret J. Transvenous balloonassisted transarterial Onyx embolization of transverse-sigmoid dural arteriovenous malformation. Neuroradiology. 2013;55(3):345-350. doi:10.1007/s00234-012-1107-8. Pop R, Manisor M, Wolff V, et al. Balloon protection of the Labbé vein during transarterial embolization of a dural arterio-venous fistula. Interv Neuroradiol. 2015;21(6):728-732. doi:10.1177/1591019915609119.
ACCEPTED MANUSCRIPT
8.
Saeed Kilani M, Izaaryene J, Cohen F, et al. Ethylene vinyl alcohol copolymer (Onyx®) in peripheral interventional radiology: Indications, advantages and limitations. Diagn Interv Imaging. 2015;96(4):319-326. doi:10.1016/j.diii.2014.11.030.
193 194 195
9.
Chiu AHY, Aw G, Wenderoth JD. Double-lumen arterial balloon catheter technique for Onyx embolization of dural arteriovenous fistulas: initial experience. J Neurointerventional Surg. 2014;6(5):400-403. doi:10.1136/neurintsurg-2013-010768.
196 197 198 199
10. Clarençon F, Di Maria F, Gabrieli J, et al. Double-lumen balloon for Onyx® embolization via extracranial arteries in transverse sigmoid dural arteriovenous fistulas: initial experience. Acta Neurochir (Wien). 2016;158(10):1917-1923. doi:10.1007/s00701-016-2906-1.
200 201 202
11. Shi Z-S, Loh Y, Duckwiler GR, Jahan R, Viñuela F. Balloon-assisted transarterial embolization of intracranial dural arteriovenous fistulas. J Neurosurg. 2009;110(5):921-928. doi:10.3171/2008.10.JNS08119.
203 204 205 206
12. Ponomarjova S, Iosif C, Mendes G a. C, Mounayer C. Endovascular Treatment of Transverse-Sigmoid Sinus Type I Dural Arteriovenous Shunts with Sinus Preservation for Patients with Intolerable Symptoms: Four Case Reports. Clin Neuroradiol. 2015;25(3):313-316. doi:10.1007/s00062-014-0343-1.
207 208 209 210 211
13. Piechowiak E, Zibold F, Dobrocky T, et al. Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus. AJNR Am J Neuroradiol. 2017;38(10):1984-1989. doi:10.3174/ajnr.A5333.
212 213 214
14. Caragine LP, Halbach VV, Dowd CF, Ng PP, Higashida RT. Parallel venous channel as the recipient pouch in transverse/sigmoid sinus dural fistulae. Neurosurgery. 2003;53(6):1261-1266-1267.
215 216 217 218
15. Kubo M, Kuwayama N, Hirashima Y, Kurimoto M, Takaku A, Endo S. Dural Arteriovenous Fistulae Developing at Different Locations after Resolution of Previous Fistulae: Report of Three Cases and Review of the Literature. Am J Neuroradiol. 2002;23(5):787-789.
220 221 222 223 224 225 226
SC
M AN U
TE D
EP
AC C
219
RI PT
189 190 191 192
FIGURE LEGENDS:
Figure 1. Preoperative images that evidence bilateral DVFAs. A. Right external carotid artery lateral. B. Right common carotid artery lateral. C. Left external carotid artery lateral. D. Left common carotid artery lateral. E. Right external carotid artery anteroposterior. F. Right common carotid artery anteroposterior. G. Left external carotid artery anteroposterior. H. Left common carotid artery anteroposterior.
ACCEPTED MANUSCRIPT
Figure 2. Procedure images that show the Copernic RC balloon inflated in the sinuses. A. Antero-posterior DSA shows deflated and inflated Copernic RC balloon in the right transverse and sigmoid sinus. B. Lateral DSA shows deflated and inflated Copernic RC balloon in the right transverse and sigmoid sinus. C. Right antero-posterior and lateral DSA showing inflated Copernic RC balloon during Onyx® embolization. D. Onyx® cast post- embolization with the inflated Copernic RC balloon.
RI PT
227 228 229 230 231 232 233 234 235 236 237
Figure 3. Post-procedure images that show obliteration of the feeders. A. AP right common carotid artery B. Lateral right common carotid artery. C. AP left common carotid artery D. Lateral left common carotid artery. E. Onyx® cast after the first procedure. F. Onyx® cast after the second procedure.
Figure 4. Post-procedure images Show Venous Drainage of the Sinuses. A. Lateral DSA in venous phase of right TS and SG sinuses, and IJV showing adequate patency. B. Lateral DSA in venous phase of left TS and SG sinuses, and IJV showing adequate patency. C. AP DSA in venous phase showing bilateral patency of venous sinus drainage.
M AN U
239 240 241 242
SC
238
AC C
EP
TE D
243
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Highlights Previous endovascular treatment of DAVF involved venous occlusive strategies. Transvenous balloon occlusion aids embolization by protecting the venous sinus. Transvenous balloon assistance can reduce the amount of embolic agent required
AC C
EP
TE D
M AN U
SC
RI PT
• • •
ACCEPTED MANUSCRIPT
Abbreviations: Dural Arterio-venous fistulas (DAVFs), Middle Meningeal Artery (MMA), internal
AC C
EP
TE D
M AN U
SC
RI PT
jugular vein (IJV), External Carotid Artery (ECA), Common Carotid Artery (CCA).
S1878-8750(17)31811-9
DOI:
10.1016/j.wneu.2017.10.083
Reference:
WNEU 6736
To appear in:
World Neurosurgery
Received Date: 13 September 2017 Revised Date:
13 October 2017
Accepted Date: 14 October 2017
Please cite this article as: Alturki A, Enriquez-Marulanda A, Schmalz P, Ogilvy CS, Thomas AJ, ® Transarterial Onyx Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist - Initial US Experience with the Copernic RC Venous Remodeling Balloon, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.10.083. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Transarterial Onyx® Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist -- Initial US Experience with the Copernic RC Venous Remodeling Balloon
5
Abdulrahman Alturki, MBBS, MSc, FRCSC1,2 *, Alejandro Enriquez-Marulanda, M.D.1 *, Philip
6
Schmalz M.D.1,3, Christopher S. Ogilvy, M.D.1, Ajith J. Thomas, M.D. 1
7
RI PT
1 2 3 4
1
Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,
MA, USA 2Department of Neurosurgery, The National Neuroscience Institute, King Fahad Medical
9
City, Riyadh, Saudi Arabia. 3Department of Neurosurgery, University of Alabama, Birmingham,
10
AL, USA.
11
*These authors contributed equally to this study.
12
Keywords: Dural arteriovenous fistulas; Therapeutic embolization; balloon-assisted technique;
13
sinus protection; Meningeal arteries; Intracranial pressure; Balloon occlusion; Dimethyl sulfoxide;
14
Tantalum
15
Running Head: Balloon-assisted protection during Onyx embolization.
16
Corresponding Author
17
Ajith J. Thomas, M.D.
18
Neurosurgical Service
19
Beth Israel Deaconess Medical Center
20
Harvard Medical School
21
110 Francis Street
22
Boston, MA, 02215
23
Email: [email protected]
24
Phone: 617-632-9785
25
AC C
EP
TE D
M AN U
SC
8
Introduction
®
ACCEPTED MANUSCRIPT
Dural-Arterio-venous-fistulas(DAVFs) consists of anomalous connections between
27
branches of dural arteries to dural venous sinuses, dural veins, meningeal veins or cortical
28
veins1. These vascular lesions account for approximately 15% of arteriovenous
29
malformation and most commonly involve the transverse and the sigmoid sinus2–4. DAVFs
30
can be asymptomatic but also can be associated with either intracranial hemorrhage
31
(especially when there is cortical venous drainage and cortical reflux), venous hypertension
32
and non-hemorrhagic neurologic deficits1–3.
33
Treatment options for DAVF include observation, microsurgery, stereotactic radiosurgery,
34
vascular embolization or a combination of these modalities4–6. Currently, the mainstay of
35
treatment for DAVFs involves endovascular approaches, especially for high-grade lesions
36
that are associated with higher risks of complications1. Low-grade lesions may be
37
considered for endovascular treatment if associated with bothersome symptoms, such as
38
intractable tinnitus or headaches.
39
Transarterial embolization with preservation of the venous sinus has become the preferred
40
approach due to the development of newer liquid embolic agents such as Onyx®(ev3
41
Endovascular, Plymouth, MN)7. Onyx® is a non-adhesive agent that polymerizes gradually
42
in contact with blood that allows controllable penetration, high occlusion rates and low
43
procedure-related complications8. Because of its ability to enter small vessels, it is
44
important to be attentive to progression and migration of Onyx®, especially when
45
potentially dangerous anastomoses are present8. Two significant drawbacks with Onyx® are
46
the possibility of arterial reflux alongside the delivery microcatheter and inadvertent venous
47
penetration beyond the venous side of the fistula, even compromising the lumen of the
48
venous sinuses9.
AC C
EP
TE D
M AN U
SC
RI PT
26
ACCEPTED MANUSCRIPT
For further precision and avoidance of venous sinus compromise and sacrifice during
50
embolization, the use of a temporary balloon occlusion to protect the patency of dural
51
sinuses from embolic agents migration have been described in few publications outside the
52
US4,4–7,9–13. Here we present a case of bilateral symptomatic Borden Type II and Cognard
53
type IIB DAVF treated successfully with transarterial Onyx® embolization with
54
transvenous balloon protection of the sinus. This case is the first reported use of the
55
Copernic® RC balloon(BALT Extrusion, Montmorency, France) in the United States under
56
the “compassionate use” guidelines of the FDA.
M AN U
SC
RI PT
49
Materials and methods
57
Case description
59
A 64-year-old man, with past medical history of hypertension, dyslipidemia, renal cell
60
carcinoma(in remission) and a former smoker, presented with bilateral pulsatile tinnitus and
61
visual decline.
62
On exam, he was found to have bilateral papilledema. Radiologic evaluation consisting of
63
an MRI and MRA of the brain and a diagnostic cerebral angiogram demonstrated a
64
complex bilateral type 2 dural arteriovenous fistula with feeding vessels from bilateral
65
occipital and middle meningeal, left ascending cervical, bilateral marginal tentorial arteries,
66
and posterior meningeal branch of the right vertebral artery(Figure 1). Retrograde venous
67
reflux through the superior sagittal sinus was noted. The principal venous drainage from
68
the brain was through enlarged scalp and superficial veins rather than the dural venous
69
sinuses, indicating venous hypertension.
AC C
EP
TE D
58
ACCEPTED MANUSCRIPT
After multidisciplinary team discussion and review of available literature, treatment was
71
offered. Surgical strategy consisted of transarterial Onyx® embolization with venous sinus
72
balloon-assisted protection technique since both transverse sinus and sagittal sinus was
73
involved in drainage of the fistula.
74
Following IRB approval, we obtained "compassionate use" FDA approval of the Copernic®
75
RC balloon for one time use to repair this DAVF.
76
Endovascular treatment technique
77
Treatment was carried out endovascularly under general anesthesia in a staged fashion. The
78
second session was delayed one week to observe for deficits and allow for patient recovery.
79
Via transfemoral arterial access, the right posterior division of the middle meningeal
80
artery(MMA)
81
microcatheter(MicroVention, Tustin, CA, USA) through a 6F Benchmark(Penumbra,
82
Alameda, CA) guiding catheter in the ECA. Transfemoral venous access was also
83
established and the Copernic® RC 10x80mm balloon was positioned in the right transverse-
84
sigmoid sinus across the torcula into the left transverse sinus. The balloon was inflated
85
during embolization to protect the right transverse sigmoid venous sinus system and
86
torcula(Figure 2). After creating satisfactory cast in the MMA distribution, the balloon was
87
pulled back into the right transverse sigmoid sinus and catheterization of the right occipital
88
artery with a double lumen Scepter XC 4x11mm balloon(MicroVention, Tustin, CA, USA)
89
was performed(Figure 3). Onyx® was then delivered through the working lumen of the
90
inflated arterial balloon until distal penetration was judged sufficient with the Copernic®
91
RC balloon inflated during the embolization session. There was a venous pouch in parallel
SC
M AN U
selectively
catheterized
with
a
Headway®
Duo
167cm
AC C
EP
TE D
was
RI PT
70
ACCEPTED MANUSCRIPT
to the sigmoid sinus which had fistulous communications from the ascending pharyngeal
93
artery which drained into the jugular vein(Figure 3B). This anatomical variant has been
94
described in previous studies14. We elected not to embolize this component since the risk of
95
cranial nerve deficit would have been high.
96
The patient was observed overnight and after an unremarkable hospital course, was
97
discharged on postoperative day one.
98
In the second stage, the Copernic® RC 10x80mm balloon was positioned in the left
99
sigmoid-transverse system through the right internal jugular vein due to difficult left sided
100
venous access to the dural sinuses. The balloon was again inflated to protect the left
101
transverse sigmoid venous sinus system and torcula during embolization. The left occipital
102
artery was catheterized with a double lumen Scepter XC 4x11mm.
103
Complete obliteration of the left DAVF was achieved and patency of the left transverse and
104
sigmoid sinuses was preserved(Figure 4B&C).
105
sigmoid sinus was also conserved post-procedure(Figure 4A&C). The patient recovered
106
overnight without signs of neurologic deficit and was again released on postoperative day
107
one.
SC
M AN U
TE D
EP
AC C
108
RI PT
92
Patency of the right transverse and
Discussion
109
Previous approaches to endovascular treatment of DAVFs involved venous occlusive
110
strategies such as coil embolization of the involved dural venous sinus. This deconstructive
111
approach risks worsening venous hypertension due to inadequate cerebral venous drainage,
112
particularly in the setting of inadequate contralateral venous sinus drainage4,5. The strategy
ACCEPTED MANUSCRIPT
of venous sinus occlusion may also cause new lesion formation due to compromised
114
venous drainage.5,15
115
With improved endovascular devices, approaches which preserve venous drainage have
116
been advocated4. Transvenous balloon-assisted transarterial Onyx® embolization for
117
DAVFs was first described by Shi et al. in 200911. This case demonstrated safe occlusion of
118
DAVF via transarterial means with preservation of the venous sinuses using transvenous
119
balloons.
120
Transvenous balloon occlusion facilitates embolization by both protecting the patency of
121
the venous sinus as well as allowing liquid embolic infiltration into otherwise inaccessible
122
meningeal vessels contributing to the fistula.6,9,11. This technique may also decrease the
123
number of embolization sessions and improve the chance of anatomical cure11.
124
Additionally, transvenous balloon assistance can reduce the amount of embolic agent
125
required.6.
126
The Copernic® RC Venous Remodeling Balloon, was selected for this case. This is a low-
127
pressure, compliant hydrophilic balloon. The balloon is DMSO-compatible and has a
128
diameter of up to 10x80mm6. Designed for use with a 6F guide catheter and is designed for
129
use with the Trascend 0.014 microwire(Boston scientific, Miami, FL); though in this case a
130
Synchro2 Standard wire was used without difficulty. Reports using other devices have
131
shown incomplete sinus occlusion and consequent off-target embolization5.
132
The MMA has been described as the gateway for successful embolization of these
133
lesions.3,5,13 Transverse sinus DAVFs are commonly fed by branches from the middle and
134
posterior meningeal artery, by meningeal branches from the ascending pharyngeal artery,
AC C
EP
TE D
M AN U
SC
RI PT
113
ACCEPTED MANUSCRIPT
and by transosseous branches of the occipital artery or, more rarely, of the superficial
136
temporal artery10. It is essential that meticulous fluoroscopic monitoring during Onyx®
137
injection is performed to be aware of any possible reflux or migration of the embolic
138
agent11. Also, for further reduction of the risk of migration into the parent artery, the use of
139
a transarterial dual-lumen complement balloon poses the advantage that the inflation of the
140
balloon in the feeder vessels avoids the need of a proximal Onyx® plug to prevent the
141
reflux9,10, giving an additional safeguard during the procedure.
142
One of the major concerns of transvenous balloon-assisted-technique is the pressure
143
changes within the intracranial venous drainage when the balloon is inflated, which might
144
cause intracranial hypertension or venous territory infarctions6. A balloon inflation test may
145
be performed before embolization to assess venous compromise4,6. In cases of embolization
146
involving a dominant venous sinus the balloon may be periodically deflated to reduce the
147
risk of venous infarction4,6. Systemic heparinization should also be considered to minimize
148
the risk of thrombosis of the dural sinus6.
149
Risk of Onyx migration to a parallel venous channel is also possible when it is not
150
adequately protected by the venous balloon.
151
described a case in which migration of Onyx was evidenced in a patient with a Borden type
152
II fistula into the proximal vein of Labbé despite the use of venous balloon protection. The
153
intervention, however, was stopped timely and no impairment of the patency of the vein
154
was noted13. In our case there was evidence of a parallel venous channel of the right
155
sigmoid sinus which had fistulous communications from the ascending pharyngeal artery
156
which drained into the jugular vein. We elected to not embolize this component due to the
157
risk of cranial nerve deficit.
In the series of Piechowiak et al. they
AC C
EP
TE D
M AN U
SC
RI PT
135
ACCEPTED MANUSCRIPT
Conclusions
159
Transvenous and transarterial balloon-assisted transarterial Onyx® embolization is
160
becoming a useful treatment alternative in selected cases of DAVFs. Previous reports in
161
Asia and Europe with venous remodeling balloons are encouraging. We report the first
162
known experience with this device in USA. The device performed as expected and there
163
were no complications attributable to the device. Additionally, it provided a valuable
164
adjunct to improve the safety and efficacy of transarterial embolization. References
M AN U
165
SC
RI PT
158
1.
Gandhi D, Chen J, Pearl M, Huang J, Gemmete JJ, Kathuria S. Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment. AJNR Am J Neuroradiol. 2012;33(6):1007-1013. doi:10.3174/ajnr.A2798.
169 170 171
2.
Kwon BJ, Han MH, Kang H-S, Chang K-H. MR imaging findings of intracranial dural arteriovenous fistulas: relations with venous drainage patterns. AJNR Am J Neuroradiol. 2005;26(10):2500-2507.
172 173 174
3.
Griessenauer CJ, He L, Salem M, Chua MH, Ogilvy CS, Thomas AJ. Middle meningeal artery: Gateway for effective transarterial Onyx embolization of dural arteriovenous fistulas. Clin Anat N Y N. 2016;29(6):718-728. doi:10.1002/ca.22733.
175 176 177 178
4.
Choi BJ, Lee TH, Kim CW, Choi CH. Reconstructive treatment using a stent graft for a dural arteriovenous fistula of the transverse sinus in the case of hypoplasia of the contralateral venous sinuses: technical case report. Neurosurgery. 2009;65(5):E994996; discussion E996. doi:10.1227/01.NEU.0000351772.45417.92.
179 180 181 182
5.
Zhang Y, Li Q, Huang Q-H. Embolization of a superior sagittal sinus dural arteriovenous fistula under intrasinus balloon protection: A case report. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci. 2015;21(1):94-100. doi:10.1177/INR-2014-10098.
183 184 185
6.
186 187 188
7.
AC C
EP
TE D
166 167 168
Jittapiromsak P, Ikka L, Benachour N, Spelle L, Moret J. Transvenous balloonassisted transarterial Onyx embolization of transverse-sigmoid dural arteriovenous malformation. Neuroradiology. 2013;55(3):345-350. doi:10.1007/s00234-012-1107-8. Pop R, Manisor M, Wolff V, et al. Balloon protection of the Labbé vein during transarterial embolization of a dural arterio-venous fistula. Interv Neuroradiol. 2015;21(6):728-732. doi:10.1177/1591019915609119.
ACCEPTED MANUSCRIPT
8.
Saeed Kilani M, Izaaryene J, Cohen F, et al. Ethylene vinyl alcohol copolymer (Onyx®) in peripheral interventional radiology: Indications, advantages and limitations. Diagn Interv Imaging. 2015;96(4):319-326. doi:10.1016/j.diii.2014.11.030.
193 194 195
9.
Chiu AHY, Aw G, Wenderoth JD. Double-lumen arterial balloon catheter technique for Onyx embolization of dural arteriovenous fistulas: initial experience. J Neurointerventional Surg. 2014;6(5):400-403. doi:10.1136/neurintsurg-2013-010768.
196 197 198 199
10. Clarençon F, Di Maria F, Gabrieli J, et al. Double-lumen balloon for Onyx® embolization via extracranial arteries in transverse sigmoid dural arteriovenous fistulas: initial experience. Acta Neurochir (Wien). 2016;158(10):1917-1923. doi:10.1007/s00701-016-2906-1.
200 201 202
11. Shi Z-S, Loh Y, Duckwiler GR, Jahan R, Viñuela F. Balloon-assisted transarterial embolization of intracranial dural arteriovenous fistulas. J Neurosurg. 2009;110(5):921-928. doi:10.3171/2008.10.JNS08119.
203 204 205 206
12. Ponomarjova S, Iosif C, Mendes G a. C, Mounayer C. Endovascular Treatment of Transverse-Sigmoid Sinus Type I Dural Arteriovenous Shunts with Sinus Preservation for Patients with Intolerable Symptoms: Four Case Reports. Clin Neuroradiol. 2015;25(3):313-316. doi:10.1007/s00062-014-0343-1.
207 208 209 210 211
13. Piechowiak E, Zibold F, Dobrocky T, et al. Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus. AJNR Am J Neuroradiol. 2017;38(10):1984-1989. doi:10.3174/ajnr.A5333.
212 213 214
14. Caragine LP, Halbach VV, Dowd CF, Ng PP, Higashida RT. Parallel venous channel as the recipient pouch in transverse/sigmoid sinus dural fistulae. Neurosurgery. 2003;53(6):1261-1266-1267.
215 216 217 218
15. Kubo M, Kuwayama N, Hirashima Y, Kurimoto M, Takaku A, Endo S. Dural Arteriovenous Fistulae Developing at Different Locations after Resolution of Previous Fistulae: Report of Three Cases and Review of the Literature. Am J Neuroradiol. 2002;23(5):787-789.
220 221 222 223 224 225 226
SC
M AN U
TE D
EP
AC C
219
RI PT
189 190 191 192
FIGURE LEGENDS:
Figure 1. Preoperative images that evidence bilateral DVFAs. A. Right external carotid artery lateral. B. Right common carotid artery lateral. C. Left external carotid artery lateral. D. Left common carotid artery lateral. E. Right external carotid artery anteroposterior. F. Right common carotid artery anteroposterior. G. Left external carotid artery anteroposterior. H. Left common carotid artery anteroposterior.
ACCEPTED MANUSCRIPT
Figure 2. Procedure images that show the Copernic RC balloon inflated in the sinuses. A. Antero-posterior DSA shows deflated and inflated Copernic RC balloon in the right transverse and sigmoid sinus. B. Lateral DSA shows deflated and inflated Copernic RC balloon in the right transverse and sigmoid sinus. C. Right antero-posterior and lateral DSA showing inflated Copernic RC balloon during Onyx® embolization. D. Onyx® cast post- embolization with the inflated Copernic RC balloon.
RI PT
227 228 229 230 231 232 233 234 235 236 237
Figure 3. Post-procedure images that show obliteration of the feeders. A. AP right common carotid artery B. Lateral right common carotid artery. C. AP left common carotid artery D. Lateral left common carotid artery. E. Onyx® cast after the first procedure. F. Onyx® cast after the second procedure.
Figure 4. Post-procedure images Show Venous Drainage of the Sinuses. A. Lateral DSA in venous phase of right TS and SG sinuses, and IJV showing adequate patency. B. Lateral DSA in venous phase of left TS and SG sinuses, and IJV showing adequate patency. C. AP DSA in venous phase showing bilateral patency of venous sinus drainage.
M AN U
239 240 241 242
SC
238
AC C
EP
TE D
243
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Highlights Previous endovascular treatment of DAVF involved venous occlusive strategies. Transvenous balloon occlusion aids embolization by protecting the venous sinus. Transvenous balloon assistance can reduce the amount of embolic agent required
AC C
EP
TE D
M AN U
SC
RI PT
• • •
ACCEPTED MANUSCRIPT
Abbreviations: Dural Arterio-venous fistulas (DAVFs), Middle Meningeal Artery (MMA), internal
AC C
EP
TE D
M AN U
SC
RI PT
jugular vein (IJV), External Carotid Artery (ECA), Common Carotid Artery (CCA).