Endovascular treatment of vertebro-vertebral arteriovenous fistula. A report of three cases and literature review

Abstract

This report describes endovascular approaches for occlusion of vertebro-vertebral arteriovenous fistula (VV-AVF) in a series of three cases and a review of the literature. Complete neuroimaging assessment, including CT, MR and DSA was performed in three patients (two female, one male) with VV-AVF. Based on DSA findings, the VV-AVF were occluded by endovascular positioning of detachable balloons (case 1), coils (case 2), or a combination of both (case 3) with parent artery patency in two out of three cases. In this small series, endovascular techniques for occlusion of VV-AVF were safe and effective methods of treatment. To date, there are no guidelines on the best treatment for VV-AVF. Detachable balloons, endovascular coiling, combined embolization procedures could all be considered well-tolerated treatments.

Figure 1

A) Sagittal T2-w MRI shows a right ectasic vertebral artery at the anterior epidural level; B) Preoperative right vertebral artery DSA shows a direct VV-AVF between the right VA at C2 level and the periradicular venous plexus.

Figure 2

Operative DSA (A-C): the balloon is detached at the fistula point with preservation of parent vertebral artery patency.

Figure 3

Axial MRA TOF 3D (A) and MIP reconstruction (B) showing an extradural fistula of the vertebral artery involving the perivertebral venous plexus at C3-C4 level. Vertebral artery DSA (C, D) shows a dilated extracranial segment of the right vertebral artery between the muscular branches of the vertebral artery and a dilated periradicular venous plexus.

Figure 4

Vertebral artery operative DSA (A-C) shows complete occlusion of the fistula with coils and preservation of right vertebral artery patency.

Figure 5

Contrast-enhanced CT angiography, MPR reconstruction (A) axial (B) coronal (C) sagittal, shows an extradural fistula of the right VA with multiple arteriovenous high-flow shunts at C2-C5 level. Pre-operative DSA right (D) and left (E) VA injection: large VVAF in NF1 with flow steal.

Figure 6

Operative DSA: partial occlusion with detachable balloon (A). Complete VA and fistula occlusion with further coiling (B). C) Post-embolization DSA by controlateral VA injection shows patency of the right PICA.