A promising adjuvant to detachable coils for cavernous packing: onyx

Abstract

Transvenous embolization of cavernous dural arteriovenous fistulae (CDAVFs) with Onyx has recently been reported. This study was undertaken to assess the value of Onyx in transvenous treatment of CDAVFs. We retrospectively reviewed 18 patients who underwent transvenous embolization for CDAVFs of Barrow Type D with detachable coils and Onyx at our institution over five years. Patients were divided into two groups: group A, patients who had been treated with detachable coils; group B, patients who had been treated with a combination of detachable coils and Onyx. The approach routes, angiographic results, complications and clinical outcome were assessed for both groups. Eighteen patients with CDAVFs of Barrow Type D were treated: nine women and nine men; mean age was 41.9 years. Eleven patients treated by 19 procedures of transvenous coiling belonged to group A. Seven patients treated by eight procedures of transvenous Onyx injection belonged to group B. The periprocedural complication rate associated with coiling for both groups was 18.2% vs 16.7% with Onyx. The duration of the procedure in both groups was 6.77-/+2.49 hours vs 3.75-/+1.63 hours with coiling vs Onyx, and the cost of Onyx was cheaper than coils. An excellent outcome was achieved in both groups: 90.9% vs 100% (group A vs group B). Our results associated with both modalities of CDAVFs treatment with clinical outcome show that transvenous embolization with Onyx is a safe alternative to detachable coils in the treatment of CDAVFs. However, more cases need to be evaluated.

Figure 1

A 44-year-old woman demonstrated right proptosis and IV cranial nerve palsy and excessive pulsatile bruits. Cerebral angiography demonstrated a cavernous DAVF of Barrow Type D/Cognard Type II. Right CCA angiogram, anteroposterior projection (A), left CCA angiogram, lateral projection (B) showing a CDAVF fed by both internal and external carotid arteries, mainly drained to the left InfPS and the right SOV. Frontal superselective angiogram of the right CS (C) showing the microcatheter positioned close to the fistula site. After embolization, anterograms of the right common carotid artery (lateral view, D) and left common carotid artery (lateral view, E) demonstrating complete occlusion of the fistula. F) Six months later, lateral angiogram of the right ICA, showing persistent filling of the residual fistula (arrow). G) Occlusion of the intercavernous sinus (arrow) with several standard coils. H) Arteriogram of the right ICA (lateral view) after complete embolization of the right-side fistula.

Figure 1

A 44-year-old woman demonstrated right proptosis and IV cranial nerve palsy and excessive pulsatile bruits. Cerebral angiography demonstrated a cavernous DAVF of Barrow Type D/Cognard Type II. Right CCA angiogram, anteroposterior projection (A), left CCA angiogram, lateral projection (B) showing a CDAVF fed by both internal and external carotid arteries, mainly drained to the left InfPS and the right SOV. Frontal superselective angiogram of the right CS (C) showing the microcatheter positioned close to the fistula site. After embolization, anterograms of the right common carotid artery (lateral view, D) and left common carotid artery (lateral view, E) demonstrating complete occlusion of the fistula. F) Six months later, lateral angiogram of the right ICA, showing persistent filling of the residual fistula (arrow). G) Occlusion of the intercavernous sinus (arrow) with several standard coils. H) Arteriogram of the right ICA (lateral view) after complete embolization of the right-side fistula.

Figure 2

A 54-year-old man demonstrated right IIIrd cranial nerve palsy. The fistula was classified as Barrow Type D/Cognard Type II. A) Angiogram of the left common carotid artery (arterial phase, anteroposterior view) demonstrating multiple fistula feeders within the wall of the intercavernous sinus (arrow), arising from the ECA and ICA, with drainage into the right CS via the intercavernous sinus and into the right InfPS. B) Angiogram of the right common carotid artery (arterial phase, anteroposterior view) demonstrating the fistula point including the right CS and the intercavernous sinus (arrow), with drainage into the left InfPS and the left CS via the intercavernous sinus. C) Unsubtracted lateral view after a transvenous approach showed the Onyx penetration of the left SOV, intracavernous sinus and the right pterygoid plexus (arrowheads). Arteriograms of the right common carotid artery (lateral view, D) and the left common carotid artery (anteroposterior view, E) showed complete embolization of the fistula.