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Interlocking detachable coils for spontaneous vertebral arteriovenous fistula
Interlocking detachable coils for spontaneous vertebral arteriovenous fistula
S h i n - l c h i Y o s h i m u r a MD N o b u o H a s h i m o t o MD K e n j i S a m p e i MD S h o g o N i s h i MD Department of Neurosurgery, National CardiovascularCentre, Suita, Osaka,Japan
We report a case o f a spontaneous vertebral arteriovenous fistula treated with interlocking detachable coils (IDC). The patient had presented with paroxysmal dizziness and a cervical bruit. Angiography demonstrated a high flow arteriovenous fistula o f the right extracranial vertebral artery. Embolisation was p e r f o r m e d via the transarterial approach using 2 IDCs. The advantage o f IDCs in the treatment o f high flow arteriovenons fistulae is discussed. Journal of Clinical Neuroscience 1996, 3(3): 261-263
©Pearson Professional 1996
Keywords: Interlocking detachable coil (IDC), Arteriovenous fistula, Vertebral artery, Endovascular technique
Introduction Endovascular techniques with detachable balloons or coils have contributed to the t r e a t m e n t of high flow arteriovenous fistulae (AVF).I 10 We r e p o r t a patient whose spontaneous high flow vertebral artery (AVF) was successfully obliterated with interlocking detachable coils (IDC). T h e usefulness of IDC as an embolic material and o u r embolisation technique for high flow AVF with a large draining vein are discussed.
Case report A 44 year old m a n had a 6 m o n t h history of paroxysmal attacks of dizziness. H e had noticed a bruit in the right side of his neck for 1 m o n t h that was b e c o m i n g progressively louder. H e was referred to the National Cardiovascular Centre. A loud pulsatile bruit was h e a r d on the right side of his neck and had maximal intensity over the right clavicle. T h e patient was neurologically intact. CT and MRI h e a d scans were normal. Cerebral angiography d e m o n s t r a t e d a high flow fistulous c o m m u n i c a t i o n between the right vertebral artery and a cervical venous plexus which then drained into the superior vena cava (Fig. 1). Retrograde filling of the vertebral venous plexus a r o u n d the vertebral artery was also demonstrated. Neither selective arteriography n o r selective venography revealed the exact location of the fistula orifice.
Treatment U n d e r local anaesthesia, transarterial embolisation was p e r f o r m e d . A 6 French guiding catheter was introduced into the right vertebral artery. The distal portion of the
Fig. 1 Anteroposteriorview of the right subclavianangiogram showingthe vertebral arteriovenousfistula and a large draining vein communicating with the superior vena cava(arrows).
J. Clin. Neuroscience Volume 3 Number 3 July 1996
261
Technical notes
Fig. 2 Anteroposterior view of the selective angiogram of the arteriovenous fistula showing the large draining vein and retrograde filling of the vertebral venous plexus around the vertebral artery. The distal portion of the vertebral artery is not clearly demonstrated (arrow), probably caused by steal phenomenon.
right vertebral artery did not opacify well because of the large shunt (Fig. 9). Following intravenous administration of 3,000 units of heparin, a Tracker 18 catheter was introduced coaxially near the fistulous portion of the vertebral artery (located at the posterolateral wall, about 4 cm distal to the origin of the vertebral artery). A microcatheter was then introduced into the vertebral venous plexus through the AV fistula. Super selective venography demonstrated a large draining vein with multiple connections to the surrounding venous plexus. Use of detachable balloons or conventional fibre coils was ruled out because they could have easily migrated into the superior vena cava; instead, IDC was chosen as the embolic material for this high flow fistula. The microcatheter was introduced into a branch of the vertebral vein and the tip of the first IDC (5 m m / 3 cm) was inserted into the vein. The end of the coil was placed in the large draining vein to prevent migration of the next coil. A second IDC of the same size was placed into the draining vein; this locked against the first coil. The high flow fistula had then completely disappeared on vertebral angiography and subclavian angiography (Figs 3 & 4). The distal portion of the vertebral artery was clearly demonstrated to be patent. Postoperatively the patient received 500 u n i t s / h of heparin for 48 h. The patient's bruit disappeared and his dizziness gradually reduced. The patient had some mild pain in the right side of the neck but this disappeared
262
Interlocking detachable coils
Fig. 3 Left anterior-oblique view of the right vertebral angiogram showing disappearance of the arteriovenous fistula and the 2 detached IDCs.The distal portion of the vertebral artery is clearly demonstrated.
within 2 days. Angiography p e r f o r m e d 1 week after the procedure confirmed complete occlusion of the fistula with no migration of the detached IDCs.
Discussion Advances in endovascular techniques have contributed to the treatment of arteriovenous fistulae by safe procedures. 1-9'11-1s Many different types of coil and detachable balloons have been developed for this purpose. T h e embolisation of high flow arteriovenous fistulae has previously required many conventional fibre coils which took a long time to place to achieve satisfactory fistula obliteration. Furthermore, in patients with a large draining vein, there was the danger that the detached coils could migrate leading to recurrence of the arteriovenous fistula, occlusion of the parent artery, and p u l m o n a r y embolism. Detachable balloons have the same disadvantages. In fact, because of their r o u n d shape, detachable balloons may migrate more easily than fibre coils. New coil systems such as Guglielmi's detachable coils (GDC) and interlocking detachable coils (IDCs) were originally developed for the embolisation of cerebral aneurysmsP '4,1°,14 These coils are soft and longer than fibre coils varying in length from 4-20 cm. In the past, an open surgical procedure, such as ligation, was p e r f o r m e d to obliterate arteriovenous fistulae. This p r o c e d u r e is, however, hazardous and can result in
J. Clin. Neuroscience Volume 3 Number 3 July 1996
Interlocking detachable coils
Technical notes Correspondence and offprint requests to: Nobuo Hashimoto MD Department of Neurosurgery National Cardiovascular Centre 5-7-1 Fujishirodai Suita, Osaka 565 Japan Tel : +81 6 833 5012 Fax : +81 6 972 7486
References
Fig, 4 Anteroposterior view of the right subclavian angiogram after embolisation also shows complete disappearance of the vertebral arteriovenous fistula and the large draining vein.
m a j o r intraoperative h a e m o r r h a g e ) 5,16 More recently, vertebral a r t e r i o v e n o u s fistulae have b e e n treated with detachable balloons or fibre coils. However, in m a n y patients with a large v e n o u s drainer, use o f these materials m a y be d a n g e r o u s because they can migrate. GDC a n d IDC differ in the way that they are d e t a c h e d . D e t a c h m e n t o f an I D C coil is mechanically controlled; d e t a c h m e n t occurs automatically w h e n the coil is p u s h e d over a m a r k o n the coil. T h e GDC system employs a low voltage c u r r e n t for the d e t a c h m e n t o f the coil which is also t h o u g h t to i n d u c e intra-aneurysmal thrombosis; c o n s e q u e n t l y there are large differences in the time r e q u i r e d for coil d e t a c h m e n t . IDC coils can be d e t a c h e d in a s h o r t time while d e t a c h m e n t o f GDC coils can take u p to 30 min. E l e c t r o t h r o m b o s i s m a y be useful for saccular a n e u r y s m s b u t n o t necessarily for a r t e r i o v e n o u s fistulae. F u r t h e r m o r e , IDCs can be d e t a c h e d instantaneously w h e n the tip a n d e n d o f the coil are correctly p o s i t i o n e d before they have a c h a n c e to migrate. T h u s the use o f IDCs is also c o n s i d e r e d suitable for arteriovenous fistulae, especially high flow a r t e r i o v e n o u s fistulae with a large v e n o u s d r a i n e r n e a r the orifice o f the fistula, as in o u r case. Received4 September 1995 Accepted for publication 27 September 1995
1. Beaujeux RL, Reizine DC, Casasco A et al. Endovascular treatment of vertebral arteriovenous fistula. Radiology 1992; 83: 361-367. 2. Freitag HJ, Grzyska U, Zeumer H. The use of the "crossover technique' in the management of a traumatic vertebro-vertebral fistula. Neuroradiology 1989; 31: 174. 3. Guglielmi G, Vinuela F, Briganti F, Duckwiler G. Carotid cavernous fistula caused by a ruptured intracavernous aneurysm: endovascular treatment by electrothrombosis with detachable coils. Neurosurgery 1992; 31: 591-597. 4. Guglielmi G, Vinuela F, DionJ, Duckwiler G. Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience.J Neurosurg 1991; 75: 8-14. 5. Halbach VV, Higashida RT, Hieshima GB. Treatment of vertebral arteriovenous fistulas. AJNR 1987; 8:1121-1128. 6. Hieshima GB, Cahan LD, Mehringer CM, BentsonJR. Spontaneous arteriovenous fistulas of cerebral vessels in association with fibromuscular dysplasia. Neurosurgery 1986; 18: 454-458. 7. Higashida RT, Halbach VV, Tsai FYet al. Intervenfional neurovascular treatment of traumatic carotid and vertebral artery lesions: results in 234 cases. AJR 1989; 153: 577-582. 8. Johnson CE, Russell EJ, Huckman MS. Resolution of spinal epidural vascular pseudotumour following balloon occlusion of a postoperative vertebral arteriovenous fistula. Neuroradiology 1990; 31: 529-532. 9. Sadasivan B, Mehta B, Dujovny M, Malik GM, AusmanJI. Balloon embolization of nontraumatic vertebral arteriovenous fistulae in children. Surg Neurol 1989; 32: 126-130. 10. Yoshimura S, Hashimoto N, Kazekawa K, Nishi S, Sampei K. Embolization of dural arteriovenous fistulas with interlocking detachable coils. AJNR 1995; 16: 322-324. 11. Debrun G, LegreJ, Kasbarian M, Tapias PL, CaronJP. Endovascular occlusion of vertebral fistulae by detachable balloons with conservation of the vertebral blood flow. Radiology 1979; 130: 141-147. 12. Lawdahl RB, Routh WD, VitekJJ, McDowell HA, Gross GM, Keller FS. Chronic arteriovenous fistulas masquerading as arteriovenous malformations: diagnostic considerations and therapeutic implications. Radiology 1989; 170: 1011-1015. 13. Rossi PL, Passariello R, Simoneth G. Control of a traumatic arteriovenous fistula by a modified Gianturco coil embolus system. AJR 1978; 131: 331-333. 14. Guglielmi G, Vinuela F, Duckwiler G e t al. Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 1992; 77: 515-524. 15. Bartal AD, LevyJ. Excision of a congenital suboccipital vertebral arteriovenous fistula. J Neurosurg 1972; 34: 452-456. 16. Olson RW, Baker Jr HL, Svien HJ. Arteriovenous fistula: a complication of vertebral angiography - a report of a case. Neurosurgery 1963; 20: 73-75.
J. Clin. Neuroscience Volume 3 Number 3 July 1996
263
S h i n - l c h i Y o s h i m u r a MD N o b u o H a s h i m o t o MD K e n j i S a m p e i MD S h o g o N i s h i MD Department of Neurosurgery, National CardiovascularCentre, Suita, Osaka,Japan
We report a case o f a spontaneous vertebral arteriovenous fistula treated with interlocking detachable coils (IDC). The patient had presented with paroxysmal dizziness and a cervical bruit. Angiography demonstrated a high flow arteriovenous fistula o f the right extracranial vertebral artery. Embolisation was p e r f o r m e d via the transarterial approach using 2 IDCs. The advantage o f IDCs in the treatment o f high flow arteriovenons fistulae is discussed. Journal of Clinical Neuroscience 1996, 3(3): 261-263
©Pearson Professional 1996
Keywords: Interlocking detachable coil (IDC), Arteriovenous fistula, Vertebral artery, Endovascular technique
Introduction Endovascular techniques with detachable balloons or coils have contributed to the t r e a t m e n t of high flow arteriovenous fistulae (AVF).I 10 We r e p o r t a patient whose spontaneous high flow vertebral artery (AVF) was successfully obliterated with interlocking detachable coils (IDC). T h e usefulness of IDC as an embolic material and o u r embolisation technique for high flow AVF with a large draining vein are discussed.
Case report A 44 year old m a n had a 6 m o n t h history of paroxysmal attacks of dizziness. H e had noticed a bruit in the right side of his neck for 1 m o n t h that was b e c o m i n g progressively louder. H e was referred to the National Cardiovascular Centre. A loud pulsatile bruit was h e a r d on the right side of his neck and had maximal intensity over the right clavicle. T h e patient was neurologically intact. CT and MRI h e a d scans were normal. Cerebral angiography d e m o n s t r a t e d a high flow fistulous c o m m u n i c a t i o n between the right vertebral artery and a cervical venous plexus which then drained into the superior vena cava (Fig. 1). Retrograde filling of the vertebral venous plexus a r o u n d the vertebral artery was also demonstrated. Neither selective arteriography n o r selective venography revealed the exact location of the fistula orifice.
Treatment U n d e r local anaesthesia, transarterial embolisation was p e r f o r m e d . A 6 French guiding catheter was introduced into the right vertebral artery. The distal portion of the
Fig. 1 Anteroposteriorview of the right subclavianangiogram showingthe vertebral arteriovenousfistula and a large draining vein communicating with the superior vena cava(arrows).
J. Clin. Neuroscience Volume 3 Number 3 July 1996
261
Technical notes
Fig. 2 Anteroposterior view of the selective angiogram of the arteriovenous fistula showing the large draining vein and retrograde filling of the vertebral venous plexus around the vertebral artery. The distal portion of the vertebral artery is not clearly demonstrated (arrow), probably caused by steal phenomenon.
right vertebral artery did not opacify well because of the large shunt (Fig. 9). Following intravenous administration of 3,000 units of heparin, a Tracker 18 catheter was introduced coaxially near the fistulous portion of the vertebral artery (located at the posterolateral wall, about 4 cm distal to the origin of the vertebral artery). A microcatheter was then introduced into the vertebral venous plexus through the AV fistula. Super selective venography demonstrated a large draining vein with multiple connections to the surrounding venous plexus. Use of detachable balloons or conventional fibre coils was ruled out because they could have easily migrated into the superior vena cava; instead, IDC was chosen as the embolic material for this high flow fistula. The microcatheter was introduced into a branch of the vertebral vein and the tip of the first IDC (5 m m / 3 cm) was inserted into the vein. The end of the coil was placed in the large draining vein to prevent migration of the next coil. A second IDC of the same size was placed into the draining vein; this locked against the first coil. The high flow fistula had then completely disappeared on vertebral angiography and subclavian angiography (Figs 3 & 4). The distal portion of the vertebral artery was clearly demonstrated to be patent. Postoperatively the patient received 500 u n i t s / h of heparin for 48 h. The patient's bruit disappeared and his dizziness gradually reduced. The patient had some mild pain in the right side of the neck but this disappeared
262
Interlocking detachable coils
Fig. 3 Left anterior-oblique view of the right vertebral angiogram showing disappearance of the arteriovenous fistula and the 2 detached IDCs.The distal portion of the vertebral artery is clearly demonstrated.
within 2 days. Angiography p e r f o r m e d 1 week after the procedure confirmed complete occlusion of the fistula with no migration of the detached IDCs.
Discussion Advances in endovascular techniques have contributed to the treatment of arteriovenous fistulae by safe procedures. 1-9'11-1s Many different types of coil and detachable balloons have been developed for this purpose. T h e embolisation of high flow arteriovenous fistulae has previously required many conventional fibre coils which took a long time to place to achieve satisfactory fistula obliteration. Furthermore, in patients with a large draining vein, there was the danger that the detached coils could migrate leading to recurrence of the arteriovenous fistula, occlusion of the parent artery, and p u l m o n a r y embolism. Detachable balloons have the same disadvantages. In fact, because of their r o u n d shape, detachable balloons may migrate more easily than fibre coils. New coil systems such as Guglielmi's detachable coils (GDC) and interlocking detachable coils (IDCs) were originally developed for the embolisation of cerebral aneurysmsP '4,1°,14 These coils are soft and longer than fibre coils varying in length from 4-20 cm. In the past, an open surgical procedure, such as ligation, was p e r f o r m e d to obliterate arteriovenous fistulae. This p r o c e d u r e is, however, hazardous and can result in
J. Clin. Neuroscience Volume 3 Number 3 July 1996
Interlocking detachable coils
Technical notes Correspondence and offprint requests to: Nobuo Hashimoto MD Department of Neurosurgery National Cardiovascular Centre 5-7-1 Fujishirodai Suita, Osaka 565 Japan Tel : +81 6 833 5012 Fax : +81 6 972 7486
References
Fig, 4 Anteroposterior view of the right subclavian angiogram after embolisation also shows complete disappearance of the vertebral arteriovenous fistula and the large draining vein.
m a j o r intraoperative h a e m o r r h a g e ) 5,16 More recently, vertebral a r t e r i o v e n o u s fistulae have b e e n treated with detachable balloons or fibre coils. However, in m a n y patients with a large v e n o u s drainer, use o f these materials m a y be d a n g e r o u s because they can migrate. GDC a n d IDC differ in the way that they are d e t a c h e d . D e t a c h m e n t o f an I D C coil is mechanically controlled; d e t a c h m e n t occurs automatically w h e n the coil is p u s h e d over a m a r k o n the coil. T h e GDC system employs a low voltage c u r r e n t for the d e t a c h m e n t o f the coil which is also t h o u g h t to i n d u c e intra-aneurysmal thrombosis; c o n s e q u e n t l y there are large differences in the time r e q u i r e d for coil d e t a c h m e n t . IDC coils can be d e t a c h e d in a s h o r t time while d e t a c h m e n t o f GDC coils can take u p to 30 min. E l e c t r o t h r o m b o s i s m a y be useful for saccular a n e u r y s m s b u t n o t necessarily for a r t e r i o v e n o u s fistulae. F u r t h e r m o r e , IDCs can be d e t a c h e d instantaneously w h e n the tip a n d e n d o f the coil are correctly p o s i t i o n e d before they have a c h a n c e to migrate. T h u s the use o f IDCs is also c o n s i d e r e d suitable for arteriovenous fistulae, especially high flow a r t e r i o v e n o u s fistulae with a large v e n o u s d r a i n e r n e a r the orifice o f the fistula, as in o u r case. Received4 September 1995 Accepted for publication 27 September 1995
1. Beaujeux RL, Reizine DC, Casasco A et al. Endovascular treatment of vertebral arteriovenous fistula. Radiology 1992; 83: 361-367. 2. Freitag HJ, Grzyska U, Zeumer H. The use of the "crossover technique' in the management of a traumatic vertebro-vertebral fistula. Neuroradiology 1989; 31: 174. 3. Guglielmi G, Vinuela F, Briganti F, Duckwiler G. Carotid cavernous fistula caused by a ruptured intracavernous aneurysm: endovascular treatment by electrothrombosis with detachable coils. Neurosurgery 1992; 31: 591-597. 4. Guglielmi G, Vinuela F, DionJ, Duckwiler G. Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience.J Neurosurg 1991; 75: 8-14. 5. Halbach VV, Higashida RT, Hieshima GB. Treatment of vertebral arteriovenous fistulas. AJNR 1987; 8:1121-1128. 6. Hieshima GB, Cahan LD, Mehringer CM, BentsonJR. Spontaneous arteriovenous fistulas of cerebral vessels in association with fibromuscular dysplasia. Neurosurgery 1986; 18: 454-458. 7. Higashida RT, Halbach VV, Tsai FYet al. Intervenfional neurovascular treatment of traumatic carotid and vertebral artery lesions: results in 234 cases. AJR 1989; 153: 577-582. 8. Johnson CE, Russell EJ, Huckman MS. Resolution of spinal epidural vascular pseudotumour following balloon occlusion of a postoperative vertebral arteriovenous fistula. Neuroradiology 1990; 31: 529-532. 9. Sadasivan B, Mehta B, Dujovny M, Malik GM, AusmanJI. Balloon embolization of nontraumatic vertebral arteriovenous fistulae in children. Surg Neurol 1989; 32: 126-130. 10. Yoshimura S, Hashimoto N, Kazekawa K, Nishi S, Sampei K. Embolization of dural arteriovenous fistulas with interlocking detachable coils. AJNR 1995; 16: 322-324. 11. Debrun G, LegreJ, Kasbarian M, Tapias PL, CaronJP. Endovascular occlusion of vertebral fistulae by detachable balloons with conservation of the vertebral blood flow. Radiology 1979; 130: 141-147. 12. Lawdahl RB, Routh WD, VitekJJ, McDowell HA, Gross GM, Keller FS. Chronic arteriovenous fistulas masquerading as arteriovenous malformations: diagnostic considerations and therapeutic implications. Radiology 1989; 170: 1011-1015. 13. Rossi PL, Passariello R, Simoneth G. Control of a traumatic arteriovenous fistula by a modified Gianturco coil embolus system. AJR 1978; 131: 331-333. 14. Guglielmi G, Vinuela F, Duckwiler G e t al. Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 1992; 77: 515-524. 15. Bartal AD, LevyJ. Excision of a congenital suboccipital vertebral arteriovenous fistula. J Neurosurg 1972; 34: 452-456. 16. Olson RW, Baker Jr HL, Svien HJ. Arteriovenous fistula: a complication of vertebral angiography - a report of a case. Neurosurgery 1963; 20: 73-75.
J. Clin. Neuroscience Volume 3 Number 3 July 1996
263