Onyx 18 embolisation of dural arteriovenous fistula via arterial and venous pathways: preliminary experience and evaluation of the short-term outcomes

Abstract

Objective: This paper mainly focuses on our preliminary experience and short-term outcome evaluation of embolisation of non-cavernous dural arteriovenous fistulas (ncsDAVFs) and cavernous sinus dural arteriovenous fistulas (csDAVFs) using Onyx 18 (ev3, Plymouth, MN), and in combination with coils, via arterial and venous approaches, respectively.

Methods: Between August 2008 and March 2010, 21 DAVFs (11 ncsDAVFs and 10 csDAVFs; age range: 28-68 years; 12 females and 9 males) were undertaken. Borden classification showed Type III in 1 and Type II in 10 ncsDAVFs, and Type II in 4 and Type I in 6 csDAVFs. Onyx 18 was used in 11 ncsDAVFs (10 via single feeder and 1 via 2 feeders). Onyx 18 or in combination with coils was used in 10 csDAVFs (9 via the inferior petrosal sinus and 1 via the superior ophthalmic vein).

Results: Total occlusion in immediate angiography was achieved in 18 cases (85.7%; 10 ncsDAVFs and 8 csDAVFs), and near-total occlusion in 1 ncsDAVF and 2 csDAVFs. Onyx 18 was migrated into normal vasculature in two ncsDAVFs without any sequelae. One csDAVF had VI cranial nerve palsy post-operatively, which completely recovered 2 weeks post-embolisation. Follow-up angiography at 3-12 months showed complete occlusion in 20 cases (95.2%; 10 ncsDAVFs and 10 csDAVFs). One ncsDAVF (4.8%) recurred after 3 months and was successfully re-embolised.

Conclusion: Preliminary results achieved after embolising 11 ncsDAVFs and 10 csDAVFs using Onyx 18 and in combination with coils via arterial and venous pathways, respectively, appeared to be safe, feasible and effective, as 95.2% of cases were totally occluded without any clinical sequelae.

Figure 1

Digital subtraction angiography showing embolisation of cavernous dural arteriovenous fistula via the undeveloped inferior petrosal sinus. (a, b) Arteriography of right internal and external carotid arteries and (c, d) arteriography of left internal carotid artery showing dural arteriovenous fistula of right cavernous sinus and intercavernous sinus (arrow). (e) Guide wire guiding through the non-visualised inferior petrosal sinus (arrow). (f) Deployed coils. (g) Cast of Onyx 18. (h–j) Completed occlusion at 3 months post embolisation (arrow).

Figure 2

Digital subtraction angiography showing embolisation of cavernous dural arteriovenous fistula via IPS. (a, b) Arteriography of right internal carotid artery and (c, d) arteriography of right external and left internal carotid artery showing dural arteriovenous fistula of both cavernous sinuses. (e, f) Microcatheter guiding via inferior petrosal sinus. (g, h) Arteriography of right internal carotid artery and (i, j) arteriography of right external left internal carotid artery showing complete occlusion at 3-months post-embolisation (arrow).

Figure 3

Digital subtraction angiography showing complete occlusion of torcular herophili dural arteriovenous fistula via transarterial approach. (a) Left vertebral arteriography and (b, c) arteriography of right external carotid showing dural arteriovenous fistula at torcular herophili. (d) Cast of Onyx 18 reflux (arrow). (e) Left vertebral arteriography and (f) right external carotid arteriography showing compete occlusion of dural arteriovenous fistula.

Figure 4

Digital subtraction angiography showing complete occlusion of frontal region dural arteriovenous fistula via middle meningeal artery. (a, b) Arteriography of right internal and external carotid artery and (c, d) arteriography of left internal and external carotid artery showing dural arteriovenous fistula on frontal region. (e) Microcatheter guiding through the left middle meningeal artery (arrow). (f) Cast of refluxed Onyx 18 (arrow). (g, h) Arteriography of right and left internal carotid artery and (i, j) arteriography of right and left external carotid showing complete occlusion at 6 months post-embolisation. IMA, internal maxillary artery; LICA, left internal carotid artery; LIMA: left internal maxillary artery; LMMA: left middle meningeal artery; LOA, left ophthalmic artery: LSTA: left superficial temporal artery; MMA: middle meningeal artery; OA, ophthalmic artery; RECA: right external carotid artery; RICA: right internal carotid artery; RIMA: right internal maxillary artery; ROA, right ophthalmic artery; RSTA: right superficial temporal artery; STA: superficial temporal artery.