Transvenous embolization of vein of galen aneurysmal malformations using the "Chapot pressure cooker" technique

Abstract

Methods: Two patients, one 5-year-old and one 7-year-old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n-BCA for choroidal VGAMs.

Results: We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform TVE using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils and n-BCA are used to prevent reflux of Onyx.

Conclusions: In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: (1) without liquid embolic, deployed coils may not occlude the fistula entirely. (2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE.

Keywords: AVM; embolization; pressure cooker; transvenous; vein of galen.

Figure 1.

Case 1 choroidal VGAM – Newborn baby female (a) received four prior n-BCA TAEs which controlled CHF, caused significant decrease of flow, and shrank the draining vein by the age of eight (b). A 7F guiding catheter was placed in the falcine sinus (C) through a transfemoral venous approach with radial artery monitoring. Two detachable-tip Apollo 3-cm microcatheters were placed in the dilated vein of Galen at the fistula site (c-A1/c-A2), and Headway 17 microcatheter was placed between their detachable markers for coiling (c-H). Under hypotension, the dilated vein of Galen was embolized with EVOH liquid embolic material (Onyx 18) was injected to close the fistula (d). The cast confirmed a complete filling of the fistula (e). Complete occlusion of the VGAM was confirmed in the follow up angiogram (f).

Figure 2.

Case 2– A newborn boy originally presented with a choroidal VGAM (a). A total of 14 n-BCA or ONYX TAEs of the recruited dural supply shrank the VGAM significantly by the age of six (b). A 7F guiding catheter was placed in the falcine sinus through a right cervical transjugular approach and two detachable Apollo-tip 3 cm microcatheters were placed in the dilated VOG at the fistula (c-A1/A2). Under hypotension, the dilated VOG was embolized with EVOH liquid embolic material (d). Following this, the liquid embolic penetrated nicely into the complicated network (e). Complete occlusion of the VGAM was confirmed in the follow up angiogram (f).