Venous embolization of dural arterio-venous fistulas. Transcranial approach under neuronavigation

OBJECT: Transvenous embolization is an effective treatment for dural arterio-venous fistulas. In the event of dural sinus thrombosis, embolization can be performed by direct puncture via craniectomy. We report our experience with transcranial venous embolization in two patients. METHODS: Two patients underwent transcranial venous embolization of a type-III dural arterio-venous fistula of the transverse sinus. The craniectomy was performed with neuronavigation assistance. RESULTS: The surgical approach consisted in a minimal exposure of the sinus with a drill. Neuronavigation allowed accurate placement of the craniectomy. The endovascular treatment was performed in a second stage, enabling complete and stable occlusion of the fistula in both patients. CONCLUSION: This combined treatment of dural AVFs associating craniectomy and transcranial puncture of the sinus is simple and efficient when retrograde navigation through the internal jugular vein cannot be achieved. Neuronavigation is helpful in accurately positioning the craniectomy.     

Evaluation of dural arteriovenous fistulas of cavernous sinus before and after endovascular treatment using time-resolved MR angiography

Digital subtraction angiography (DSA) is the preferred method for confirming dural arteriovenous fistulas (DAVFs), but it has the disadvantage of being invasive. In contrast, time-resolved magnetic resonance angiography (TR-MRA) is a useful, noninvasive imaging technique. The aim of this study was to compare the evaluation of DAVFs of the cavernous sinus (CS) using TR-MRA and DSA. TR-MRA and DSA were obtained in six patients with CS-DAVFs treated with endovascular surgery. TR-MRA and DSA before and after treatment were reviewed by one neuroradiologist without previous knowledge of the existence of CS-DAVFs for the detection and characterization (feeding artery and venous drainage) of CS-DAVFs. DSA showed six CS-DAVFs in the six patients. TR-MRA demonstrated a hyperintensity area in the CS at the arterial phase in six patients. DSA revealed feeding arteries and a drainage vein in all CS-DAVFs. In contrast, the feeding arteries could not be identified with TR-MRA. The details regarding venous drainage could only be speculated upon with TR-MRA as it was only partly visible on the TR-MRA images. DSA after embolization showed no CS-DAVFs in any of the six patients. TR-MRA showed no hyperintensity areas in the CS at the arterial phase in any of the six patients, and with no coil artifacts. In summary, TR-MRA could detect and diagnose CS-DAVF. However, the detail regarding anatomical feeders and draining veins remains poorly visualized by TR-MRA. In this small number of cases, TR-MRA can be a useful screening tool to detect CS-DAVF and possibly also to confirm persistent obliteration following definitive treatment.     

Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature

Dural arteriovenous fistula of the sphenobasilar sinus is a true but rare lesion that connects the meningeal arteries from both the external and internal carotid arteries to the superficial middle cerebral vein (SMCV) and dural sinus. It must be distinguished from other dural arteriovenous fistulas (DAVFs) of the middle cranial fossa, such as cavernous DAVFs and sphenoparietal sinus DAVF, because of differences in the treatment and outcome between these DAVFs. Two patients with sphenobasilar sinus DAVFs reported in the literature have been identified, but they did not simultaneously harbor intracranial meningiomas. To the best of the authors’ knowledge, the patient described here is the first case that concomitantly harbors a sphenobasilar sinus DAVF and intracranial meningioma. A 42-year-old man presented with acute subarachnoid hemorrhage. Angiography demonstrated a DAVF of the sphenobasilar sinus with a giant venous aneurysm of the SMCV. After transarterial embolization, the fistula was successfully obliterated and the giant venous aneurysm was resected microsurgically. A fortuitous small meningioma at the anterior clinoid was found and removed during the operation. The patient recovered excellently and resumed his normal activities. The relevant literature is reviewed and discussed.     

Treatment of dural arteriovenous fistula using ethylene vinyl alcohol (onyx) arterial embolization as the primary modality: short-term results

OBJECT: A dural arteriovenous fistula (DAVF) typically involves meningeal feeding arteries and can cause clinical symptoms ranging from tinnitus to rupture of draining cortical or parenchymal veins. Surgical treatment may be technically demanding. Ethylene vinyl alcohol (Onyx, ev3 Neurovascular) has several properties that make it potentially useful as a primary treatment agent for DAVF. Onyx is expected to be a permanent embolic agent. It should have a decreased risk of catheter retention when compared with other permanent embolic materials. METHODS: The authors report a series of six patients with symptomatic DAVF who were treated initially with transarterial Onyx embolization and other endovascular techniques. RESULTS: Five patients had complete occlusion of their DAVF noted on the follow-up angiogram obtained between 2 and 4 months. One patient had residual filling via a small arterial branch that was stable on follow-up angiography. None of the patients had worsening of neurological function. One case was complicated by a retained catheter fragment. CONCLUSIONS: Transarterial Onyx embolization and other endovascular methods can angiographically obliterate DAVF. In some cases, embolization allowed occlusion of multiple arterial feeding arteries from a single arterial injection. Technically, the embolization was optimized when a microcatheter position immediately adjacent to the point(s) of fistulization was achieved.     

Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: report of four technical cases

OBJECTIVE AND IMPORTANCE: Dural arteriovenous fistulae (DAVFs) with leptomeningeal drainage have an aggressive natural history. Urgent treatment is necessary to arrest neurological deterioration and to prevent the risk of intracranial hemorrhage. In many patients, a primary endovascular approach is the most appropriate and most successful treatment available. In some circumstances, however, surgical intervention is required for complete obliteration. Posterior fossa DAVFs are generally deep-seated and difficult to gain access to with standard surgical approaches. The advent of cranial base surgery allows 360-degree access to the draining venous complex or sinus via extradural bone removal. CLINICAL PRESENTATION: Four patients with posterior fossa DAVFs presented to the neurosurgical service at our institutions. One DAVF was located at the craniocervical junction, and three were tentorial DAVFs of the superior petrosal sinus. All four patients were treated surgically with extradural bone removal. INTERVENTION: Postoperative angiography documented complete obliteration of all four DAVFs. All patients had normal recoveries, with the exception of one patient who experienced persistent temporal lobe seizure activity as a result of the presenting hematoma. One patient died of unrelated causes 2 years after surgery. One postoperative temporal lobe hematoma required evacuation. CONCLUSION: Recent advances in cranial base techniques have allowed the successful obliteration of aggressive posterior fossa DAVFs with acceptable morbidity. The use of these techniques should be considered in selected patients who cannot be treated with endovascular approaches.     

Combined surgical and endovascular treatment of a spontaneous diploic arteriovenous fistula. Case report

The authors report on the case of a 28-year-old woman presenting with an intraosseous arteriovenous fistula (AVF) located in the left parietal bone. The fistula was formed by direct arteriovenous shunts connecting branches of the left middle meningeal and superficial temporal arteries with a parietal diploic vein. Drainage occurred through both the external and internal jugular venous systems. Therapy consisted of combined surgical and endovascular approaches. The results of a pathological examination of the resected AVF showed mild enlargement of the diploic space. The angiographic appearance, pathological anatomy, and treatment of this rare lesion are discussed, as is a possible relationship between diploic AVFs and the development of aneurysm bone cysts.     

Ancillary techniques to facilitate endovascular repair of aortic aneurysms.

PURPOSE: The ability to treat abdominal aortoiliac aneurysms and thoracic aortic aneurysms may be limited by coexisting arterial disease. Device deployment may be impaired by occlusive disease and tortuosity of the arteries used to access the aneurysm or by suitability of the implantation sites. In this study we describe the auxiliary procedures performed to circumvent these obstacles and thereby enable endovascular aneurysm repair. PATIENTS AND METHODS: Between January 1, 1993, and December 31, 1999, 390 patients treated for aneurysm of the aorta with endovascular devices were entered prospectively in a vascular registry. Fifty (12%) of the 390 patients required adjunctive surgical techniques to (1) create or extend the length of the proximal or distal device implantation site or (2) permit device navigation through diseased iliac arteries. Auxiliary techniques used to extend or enhance implantation sites were elephant trunk graft (n = 2), the construction of renovisceral bypass grafts (n = 1), and subclavian artery transposition (n = 2). Plication of the common iliac artery at its bifurcation was performed in conjunction with femorofemoral bypass graft in nine patients to allow preservation of pelvic circulation by avoiding internal iliac artery sacrifice. Construction of a bypass graft to transpose the internal iliac artery orifice was performed in one patient. The auxiliary techniques used to facilitate device navigation were iliac artery angioplasty or stenting (n = 8), external iliac artery endovascular endarterectomy or straightening (n = 14), endoluminal iliofemoral bypass conduit (n = 5), and the construction of an open iliofemoral bypass conduit (n = 8). RESULTS: Successful deployment of the endovascular devices was achieved in 49 (98%) of 50 patients. Auxiliary techniques were successful in providing access for endovascular device deployment in all 35 patients (100%). Mean follow-up for techniques to facilitate device navigation is 26 months for endovascular procedures and 42 months for the open bypass graft construction patients; no occlusions were observed at this moment. There were five patients with incisional hematomas that did not necessitate intervention. Fourteen (94%) of 15 patients underwent successful device implantation after the auxiliary maneuvers to enhance implantation site. Mean follow-up for implantation site manipulation is 28 months. One of the subclavian transpositions had a new onset of Horner's syndrome, two of nine patients who had common iliac artery ligated had retroperitoneal hematomas that did not necessitate interventions, and no colon ischemia was seen. The patient who underwent nonanatomic bypass grafting of viscero-renal arteries had a retroperitoneal hematoma that necessitated reexploration. CONCLUSIONS: Significant coexisting arterial disease may be encountered in patients with aortic or iliac aneurysms. Identification of coexisting arterial diseases is essential to help tailor the appropriate supplemental surgical procedure to allow the performance of endovascular aneurysm repair in patients who would otherwise require open surgical repair.     

Single stage transcranial exposure of large dural venous sinuses for surgically-assisted direct transvenous embolization of high-grade dural arteriovenous fistulas: technical note

Background  

High-grade dural arteriovenous fistulas (DAVFs) with retrograde cortical leptomeningeal drainage are formidable lesions because of their risk for intracranial hemorrhage. Treatment is aimed at occluding venous outflow to achieve obliteration of the fistula. In DAVFs that involve a large dural venous sinus (transverse sigmoid sinus or superior sagittal sinus), occluding venous outflow can be accomplished endovascularly with transvenous embolization. However, in some cases of DAVFs with reflux into cortical leptomeningeal veins, there may be venous restrictive disease downstream, such as occlusive thrombosis, which can prohibit endovascular access via the transfemoral or transjugular routes. In these instances, a transcranial approach can be performed to expose the large dural venous sinus distal to the site of occlusion for direct catheterization of the venous outflow for transvenous embolization. This combined surgical and endovascular strategy provides direct access to the venous outflow and bypasses the site of thrombotic obstruction.     

Onyx embolization of cavernous sinus dural arteriovenous fistulas via direct transorbital puncture under the guidance of three-dimensional reconstructed skull image (reports of six cases)

Backgrond

Because of complex angioarchitecture, the transarterial or venous pathway is not feasible for some cavernous sinus dural arteriovenous fistulas (CS DAVFs). We present six cases in which onyx embolization of a CS DAVFs was made possible through direct transorbital puncture.

Methods

In the present study, all patients were penetrated through one third of the medial-lateral of the inferior orbital rim under the guidance of fluoroscopy superimposed on the three-dimensional reconstructed skull image to complete embolization (onyx with or without coils). The records of patient demographics, clinical manifestation, fistula features, procedures, clinical outcome and angiographic outcome were reviewed and analyzed.

Results

In our series of six patients, the immediate angiographic result showed complete occlusion in all patients. The six patients experienced retrobulbarhematoma and eye swelling right after embolization, while the swelling significantly subsided after 3–5 days of conservative treatment. During the postoperative angiography and clinical follow-up (4–10 months), one of the patients had decreased visual acuity; the other five patients did not have neurological dysfunction.

Conclusions

Onyx embolization via direct transorbital puncture provides a method to be considered to treat CS DAVFs when the conventional transvenous approaches are inaccessible.     

Percutaneous transvenous embolization of a dural arteriovenous fistula through a mastoid emissary vein. Technical note

Definitive endovascular treatment of dural arteriovenous fistulas (DAVFs) requires obliteration of the site of the fistula: either the diseased dural sinus or the pial vein. Access to this site is often limited by occlusion of the sinus proximal and distal to the segment containing the fistula. The authors describe a technique in which the mastoid emissary vein is used to gain access to a Borden-Shucart Type II DAVF in the transverse-sigmoid sinus. Recognition of this route of access, if present, may facilitate endovascular treatment of these lesions. Access to the transverse sinus via this approach can be straightforward and may be underused.     

Combined surgical approach with intraoperative endovascular embolization for inaccessible dural arteriovenous fistulas

BACKGROUND: We describe an alternative treatment modality for inaccessible intracranial DAVFs caused by local thrombosis or tortuous feeder vessels. Special consideration is given to the efficacy of intraoperative endovascular embolization and to the use of various operative routes depending on the location of the lesions. METHODS: Between August 1999 and January 2006, 7 of 65 patients were diagnosed with DAVFs with the limitation of endovascular access. Thus, we adopted a combined surgical approach with intraoperative endovascular embolization. We reviewed and analyzed the patients' medical records and their outcomes. RESULTS: Depending on tumor location, a surgical approach combined with simultaneous intraoperative endovascular embolization was successfully performed via the SOV, the TS-SS junction, and the SSS. No complication related to the treatment was reported, and, subsequently, all the patients recovered completely. CONCLUSION: A combined surgical approach with simultaneous intraoperative embolization is an effective and safe treatment for DAVFs that are of limited angiographic access.     

Management,risk factors and outcome of cranial dural arteriovenous fistulae: a single-center experience

Background  

The role of endovascular interventions in managing dural arteriovenous fistulas (DAVFs) is increasing. Furthermore, in patients with aggressive DAVFs, different surgical interventions are required for complete obliteration or disconnection. Our objective was to evaluate the management of patients with intracranial DAVFs treated in our institution to identify the parameters that may help guide the long-term management of these lesions.     

Management strategies for anterior cranial fossa (ethmoidal) dural arteriovenous fistulas with an emphasis on endovascular treatment

OBJECT: Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare lesions that can cause intracranial hemorrhage. Authors of previous reports mostly have described open surgical treatment for this fistula type. The authors' purpose in the present study was to describe their experience with anterior cranial fossa DAVFs, including their endovascular treatment. METHODS: All patients with anterior cranial fossa DAVFs diagnosed and treated in 3 separate institutions during the last 23 years were retrospectively identified. Clinical charts, imaging studies, and procedural notes were evaluated. RESULTS: Twenty-four patients (22 males and 2 females), ranging in age from 3 to 77 years, harbored 24 DAVFs in the anterior cranial fossa. Eleven patients were primarily treated with surgical disconnection and 2 with radiosurgery. Eleven patients were treated endovascularly; 7 of these patients (63.6%) were cured. In 4 cases of failed embolization, final disconnection was achieved through surgery. In fact, surgery was effective in disconnecting the fistula in 100% of cases. All endovascular procedures consisted of transarterial injections of diluted glue (N-butyl cyanoacrylate [NBCA]), and there were no complications. Brain edema developed around the venous pouch and confusion was apparent after venous disconnection in 1 surgically treated patient. No patient suffered a hemorrhage during the follow-up period. CONCLUSIONS: Disconnection of an anterior cranial fossa DAVF by using transarterial catheterization through the ophthalmic artery and subsequent injection of NBCA is possible with a reasonable success rate and low risk for complications. In patients with good vascular access this procedure could be the treatment of choice, to be followed by open surgery in cases of embolization failure.     

Transcranial embolization of a transverse-sigmoid sinus dural arteriovenous fistula carried out through a decompressive craniectomy

Summary We report a case of dural arteriovenous fistula (DAVF) of the transverse-sigmoid sinus presenting with intraventricular hemorrhage. Cerebellar infarction developed after transarterial embolization, and decompressive craniectomy was performed to relieve the mass effect. Through the bone window of the decompressive craniectomy, transcranial puncture of thetransverse sinus and coil occlusion of the fistula were successfully performed. Decompressive craniectomy may provide an opportunity to occlude DAVFs which cannot be occluded by the transarterial or transvenous approach.     

Borden-Shucart Type I dural arteriovenous fistulas: clinical course including risk of conversion to higher-grade fistulas

Object The goal of this study was to determine the clinical course of Borden-Shucart Type I cranial dural arteriovenous fistulas (DAVFs) and to calculate the annual rate of conversion of these lesions to more aggressive fistulas that have cortical venous drainage (CVD). Methods A retrospective chart review was conducted of all patients harboring DAVFs who were seen at the authors' institution between 1997 and 2009. Twenty-three patients with Type I DAVFs who had available clinical follow-up were identified. Angiographic and clinical data from these patients were reviewed. Neurological outcome and status of presenting symptoms were assessed during long-term follow-up. Results Of the 23 patients, 13 underwent endovascular treatment for intolerable tinnitus or ophthalmological symptoms, and 10 did not undergo treatment. Three untreated patients died of unrelated causes. In those who were treated, complete DAVF obliteration was achieved in 4 patients, and palliative reduction in DAVF flow was achieved in 9 patients. Of the 19 patients without radiographic cure, no patient developed intracranial hemorrhage or nonhemorrhagic neurological deficits (NHNDs), and no patient died of DAVF-related causes over a mean follow-up of 5.6 years. One patient experienced a spontaneous, asymptomatic obliteration of a partially treated DAVF in late follow-up, and 2 patients experienced a symptomatic conversion of their DAVF to a higher-grade fistula with CVD in late follow-up. The annual rate of conversion to a higher-grade DAVF based on Kaplan-Meier cumulative event-free survival analysis was 1.0%. The annual rate of intracranial hemorrhage, NHND, and DAVF-related death was 0.0%. Conclusions A small number of Type I DAVFs will convert to more aggressive DAVFs with CVD over time. This conversion to a higher-grade DAVF is typically heralded by a change in patient symptoms. Follow-up vascular imaging is important, particularly in the setting of recurrent or new symptoms.     

Resection of the transverse sinuses and confluence of sinuses for treatment of multiple dural arteriovenous fistulas. Case report

Dural arteriovenous fistulas (DAVFs) occurring simultaneously at two or more separate locations are not frequent. In fact, the incidence of multiple DAVFs is 7 to 8% of all DAVFs. Patients harboring multiple DAVFs have a higher incidence of hemorrhage, venous infarction, and neurological deficits due to a greater frequency of leptomeningeal venous drainage. To the authors' knowledge only a few cases of DAVFs involving both transverse sinuses (TSs) have been reported. These patients underwent various combined treatments (transarterial embolization, transvenous obliteration, surgical isolation, resection, and radiosurgery). Treatments performed that do not include resection of the involved sinuses do not always guarantee a cure. The authors present a patient who harbored multiple DAVFs of the TSs, both distally occluded with secondary reflux into the superior sagittal sinus (SSS), the straight sinus, the deep venous system, and the leptomeningeal veins of both hemispheres. An en bloc removal of the portions including the fistulas of the TSs, the confluence of sinuses, and the distal parts of the SSS, and straight sinus allowed for the patient to be cured. The fact is emphasized that despite the progress of endovascular treatment and radiosurgery this kind of DAVF must be surgically treated. The operation may be complex and dangerous.     

The efficacy and safety of closure of brachial access using the AngioSeal closure device: experience with 161 interventions in diabetic patients with critical limb ischemia

PURPOSE: This study retrospectively evaluated the efficacy and safety of the 6F Angio-Seal (St. Jude Medical, St. Paul, Minn) as a closure device for transbrachial artery access for endovascular procedures in diabetic patients with critical limb ischemia. METHODS: From January 2005 and September 2007, 1887 diabetic patients underwent interventional procedures in the lower limbs at a two diabetic foot centers. Patients presented with rest pain (16%), ulcers (80%), or gangrene (4%). Systemic anticoagulation with sodium heparin (70 IU/kg) was obtained for all patients at the beginning of the endovascular treatment. A total of 249 brachial arteries (238 patients) were evaluated for possible Angio-Seal use after endovascular recanalization of the leg. Color Doppler ultrasound imaging of the artery was obtained before revascularization only in patients with previous Angio-Seal placement in the brachial artery. No further imaging studies were done in the remaining brachial arteries where the Angio-Seal was deployed at the operator's discretion. Impairment or disappearance of the radial pulse or onsets of hand ischemia or hand pain, or impairment of hand function during or at the end of the endovascular revascularization were all regarded as contraindications to Angio-Seal usage. Evidence of a highly calcified plaque of the brachial artery access site at the time of vessel puncture was regarded as an absolute contraindication to the Angio-Seal use. Patients were seen before discharge, at 1, 3, and 8 weeks after the procedure, and at 3-month intervals thereafter. Complications included hemorrhage, pseudoaneurysm, infection, and vessel occlusion. RESULTS: A total of 1947 Angio-Seal collagen plugs were deployed in 1709 diabetic patients (90.5%). The Angio-Seal was used for brachial artery closure in 159 patients (8.4%) in 161 procedures (159 in the left, 2 in the right brachial artery). In 79 patients (4.2%) in 88 procedures (87 in the left and 1 in the right brachial artery), the device was deemed contraindicated due to small vessel size in 73 patients (92.4%) or presence of calcium at the access site in five patients (6.3%). One patient (1.3%) refused the collagen plug closure after revascularization. The non-Angio-Seal group was evaluated for comparison. The success rate for achieving hemostasis in the Angio-Seal group was 96.9%. Five major complications (3.1%) at 30 days consisted of two puncture site hematomas >4 cm, two brachial artery occlusions, and one brachial artery pseudoaneurysm, with three patients requiring open surgery. Minor complications (7.50%) were three puncture site hematomas < 4 cm, three oozing of blood from the access site, and six patients had mild pain in the cubital fossa. No further complications were recorded in the 14-month follow-up (range 1-25 months) of a total of 140 patients. CONCLUSIONS: This retrospective study shows that the 6F Angio-Seal is a valuable and safe vascular closure device for transbrachial access in diabetic patients undergoing interventional procedures for critical limb ischemia.     

Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse-sigmoid sinus

OBJECT: The aim of this study was to assess the efficacy and safety of radiosurgery for the treatment of dural arteriovenous fistulas (DAVFs) located in the region of the transverse-sigmoid sinus. METHODS: A series of 20 patients with DAVFs located in the transverse-sigmoid sinus, who were treated with gamma knife surgery between June 1995 and June 2000, was evaluated. According to the Cognard classification, the DAVF was Type I in four patients. Type IIa in seven, Type IIb in two, and combined Type IIa+b in seven. Nine patients had previously been treated with surgery and/or embolization, whereas 11 patients underwent radiosurgery alone. Radiosurgery was performed using multiple-isocenter irradiation of the delineated DAVF nidus. The target volume ranged from 1.7 to 40.7 cm3. The margin dose delivered to the nidus ranged from 16.5 to 19 Gy at a 50 to 70% isodose level. Nineteen patients were available for follow-up review, the duration of which ranged from 6 to 58 months (median 19 months). Of the 19 patients, 14 (74%) were cured of their symptoms. At follow up, magnetic resonance imaging and/or angiography demonstrated complete obliteration of the DAVF in 11 patients (58%), subtotal obliteration (95% reduction of the nidus) in three (16%), and partial obliteration in another five (26%). There was no neurological complication related to the treatment. One patient experienced a recurrence of the DAVF 18 months after angiographic confirmation of total obliteration, and underwent a second course of radiosurgery. CONCLUSIONS: Stereotactic radiosurgery provides a safe and effective option for the treatment of DAVFs involving the transverse and sigmoid sinuses. For some aggressive DAVFs with extensive retrograde cortical venous drainage, however, a combination of endovascular embolization and surgery may be necessary.     

Surgical treatment of cranial arteriovenous malformations and dural arteriovenous fistulas

Microsurgical resection remains the treatment of choice for more than half of all patients with arteriovenous malformations (AVMs). It reduces the treatment window to a span of a few weeks and is curative. Careful patient selection, meticulous surgical planning, and painstaking technical execution of surgery are typically rewarded with excellent outcomes. For dural arteriovenous fistulas (DAVFs), microsurgical obliteration is often reserved for cases in which endovascular therapy either cannot be pursued or fails. When performed, however, microsurgical obliteration of DAVFs is associated with excellent outcomes as well. This article reviews the current state of microsurgical treatment of AVMs and DAVFs.     

Efficacy of a direct puncture approach for anterior circulation aneurysms using a newly developed guiding catheter - especially for geriatric patients

BACKGROUND: Endovascular surgery is being increasingly used as an alternative to craniotomy clipping surgery, especially for aged patients and complicated cases. However, tortuous atherosclerotic arteries sometimes interfere with advancement of catheters so that direct puncture may be necessary. Short guiding catheters for use with this approach have been newly developed, as discussed in this article. METHODS: One hundred twenty three anterior circulation aneurysms in 121 patients were consecutively treated by endovascular coil embolization, of which 42 (34%) were older than 70 years. RESULTS: With 21 aneurysms, coil embolization via the transfemoral approach failed, but all could be successfully treated with the direct puncture approach with minor complications such as 1 transient ischemic attack and 1 nonsymptomatic minor leakage. In the aged patients, the direct puncture approach with short guiding catheter resulted in complete obliteration of aneurysms in 20 (71%) of 28 with follow-up angiography. CONCLUSION: Direct puncture using newly developed short guiding catheters is an alternative to femoral approaches for patients with anterior circulation aneurysm with tortuous arteries and obvious atherosclerotic change at bifurcations of the common carotid artery.