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OPERATIVE NUANCES: STEP BY STEP (VIDEO SECTION)
Year : 2023 | Volume
: 71
| Issue : 5 | Page : 898-901
Endovascular Management of Vertebro-Vertebral Arteriovenous Fistula (VVAVF) with Trapping of the Vertebral Artery
Deepak K Singh1, Kshitij Sinha1, Mohammad Kaif1, Kuldeep Yadav1, Neha Singh2, Vipin K Chand1, Prevesh K Sharma1, Nirbhay Singh1, Virinchi K Dabbir1
1 Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Radiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Correspondence Address:
Kshitij Sinha
Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/0028-3886.388065
How to cite this article:Key Message: There is no clear-cut treatment of choice up till now but Balloon-assisted coil embolization of the fistula with trapping of the vertebral artery is a safe, reliable, and cost-effective technique in patients who tolerate Balloon Occlusion Test.
Vertebral arteriovenous fistulas, a rare entity, are an abnormal communication between the extracranial vertebral artery and surrounding veins.[1] The major causes are penetrating neck injury, iatrogenic puncture of the vertebral or carotid artery, unintentional vertebral artery damage during venous access, spine surgeries, and rarely spontaneous, which may be congenital.[2],[3],[4] The symptom ranges from bruit and neck pain to venous hypertension, spinal cord dysfunction, and mechanical compression, leading to weakness.[5]
Objective
In this video, we will demonstrate endovascular trans-arterial balloon-assisted coil embolization of the fistula with trapping of the vertebral artery
Procedure
After obtaining consent from the patient, the patient was shifted to the digital subtraction angiography (DSA) laboratory and laid supine. General anesthesia was given, and painting and draping were performed on the bilateral groin as standard. The activated clotting time was maintained between 250 and 300 s during the procedure.
A bilateral 8Fr, 13-cm femoral access sheath (Cook Medical, Bloomington, IN, USA) was used to access the femoral artery. A 6 Fr, 100-cm Envoy guide catheter (Codman Neuro, Raynham, MA, USA) was used to access the right vertebral artery via the left femoral route. Selective angiography was performed via this catheter to check for cross-flow and to give a road map of the left vertebral artery. A 6.3-Fr, 105-cm Distal access catheter (DAC) 070 intermediate catheter (Stryker Neurovascular, Fremont, CA, USA) was used to access the left vertebral artery via right femoral artery access. A 150-cm, 4 mm × 10 mm TransForm super-compliant balloon (Stryker Neurovascular) was passed via DAC and inflated distal to the fistulous opening. A 150-cm Echelon 14 microcatheter (Medtronic, Dublin, Ireland) with Synchro 200-cm micro-guide wire (Stryker Neurovascular) was inserted via DAC and was used to access the fistula site. Multiple 10 × 30 Target 360 Standard coils (Stryker Neurovascular) were placed in the left vertebral artery, obliterating the fistula site and the vertebral artery while keeping the balloon inflated. Once a sufficient number of coils were put in to block the vertebral artery, the balloon was deflated and withdrawn below the fistula. Further blocking of the involved artery was performed until the dye did not pass into the fistula, thus completing our procedure.
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Video Timeline with Audio Transcript
00:02:47–00:13:13—41-year-old man presented with chief complaints of neck pain radiating to left shoulder for 3 months with weakness in the left upper limb for 3 months.
00:13:15–00:31:17—On examination, his blood pressure was 160/110 mmHg. The power of the left shoulder in abduction and adduction was 1/5 with flexion and extension being 2/5. At the elbow, the power of the flexion and extension was 3/5, whereas at the wrist the power was 3/5.
00:31:17–01:02:42—Magnetic resonance imaging (MRI) was performed, which showed cord edema with flow voids from C3 to C6 levels in the left paracentral region arising from the left vertebral artery, leading to dilated epidural and paravertebral vascular channels and causing compression of the cervical cord.
DSA was performed, which confirmed high-flow left vertebral arteriovenous fistula at C3 to C6 levels with a direct shunt to epidural and paravertebral venous plexus. There was no filling from any other vessels.
01:02:51–01:14:39—The treatment strategies were as follows:
Surgical ligationTrans-arterial route using balloon, liquid embolizing agent (LEA), coils, and stent graftsTransvenous routeCombined01:14:40–01:50:24—We chose balloon-assisted trans-arterial coil embolization of the fistula with trapping of the left vertebral artery as
The fistula had a high flow, and the site of the fistula was less evident.The balloon prevents any distal migration of coils with tight packing.An occlusion test of the involved artery was performed and was well tolerated by the patient before the procedure.The LEA should not be used in cases of high-flow AV fistula as there are high chances of distal migration into the artery and veins, transvenous routes are reserved for large and complex multiple feeders and large grafts are required for the same, and surgical treatment is difficult, leads to suboptical ligation, and increases the chances of injury to the surrounding tissues.
01:50:26–02:09:26—The hardware required are as follows:
Femoral sheath 8 Fr (Cook Medical, Bloomington, IN, USA).Guiding catheter Envoy 6 Fr (Codman Neuro, Raynham, MA, USA).Distal access intermediate catheter.Microcatheter Echelon (Medtronic, Dublin, Ireland).TransForm Occlusion Balloon Catheter (Stryker Neurovascular, Fremont, CA, USA).Target 360 standard coils (Stryker Neurovascular, Fremont, CA, USA).02:09:29–02:47:46—After obtaining consent, the patient was laid supine in the DSA laboratory, and general anesthesia was given. The bilateral femoral puncture was taken with an 8F femoral sheath. An Envoy guiding catheter of 6 French was taken up through the left femoral artery and placed into the right vertebral artery. This was performed to get cross-flow and make road maps for the procedure.
Similarly, through the right femoral artery a distal access intermediate catheter is placed into the left vertebral artery just before the fistula site. A transform balloon and an Echelon microcatheter with micro-guide wire are inserted through the distal access intermediate catheter.
02:47:49–02:50:26—Fluoroscopy is done, and the road map is given.
02:51:00–03:11:00—TransForm balloon is placed beyond the fistula site and inflated while an Echelon microcatheter is used to put coils through it into the fistula. The coils are put through an Echelon microcatheter, where the balloon is kept inflated.
03:18:00–03:29:20—After putting in coils, we take fluoroscopy from the opposite side. We can see that the dye is still passing into the fistula. Therefore, more coils are put into the artery.
03:35:20–03:48:20—The coils are put in, keeping the balloon inflated. Once sufficient coils are put in to block the artery, the balloon is deflated and gradually withdrawn below the fistula.
03:49:10–04:11:10—After putting in more coils, fluoroscopy is taken from the contralateral side to look for the filling of the fistula. This time we can see that no dye is going into the fistula. Finally, fluoroscopy is taken from the left vertebral artery, and antero-posterior (AP) and lateral view are seen, which show no dye going into the fistula, thus completing our procedure.
04:11:13–04:30:11—Follow-up video at 1 month shows marked improvement in symptoms of the patient with immediate improvement of the blood pressure of the patient on postoperative period day 1. The immediate correction of blood pressure was attributed to a decrease in venous return once the high-flow fistula was blocked during the procedure.
OutcomeThe patient tolerated the procedure well, and at 2 months of follow-up, the patient had improvement of the weakness in the left upper limb. The blood pressure of the patient returned to normal just after the procedure.
Pearls and PitfallsWith the balloon inflated distal to the site of the fistula, there was no risk of migration of coils. Also, tight packing could be achieved.
Case description
41-year-old man presented to the neurosurgery outpatient department (OPD) with chief complaints of neck pain radiating to the left shoulder for 3 months with weakness in the left upper limb. On examination, his blood pressure was 160/110 mmHg. The power of the left shoulder in abduction and adduction was 1/5 with flexion and extension being 2/5. At the elbow, the power of the flexion and extension was 3/5, whereas at the wrist the power was 3/5.
An MRI was performed, which showed cord edema with flow voids from C3 to C6 levels in the left paracentral region arising from the left vertebral artery, leading to dilated epidural and paravertebral vascular channels and causing compression of the cervical cord.
DSA was performed, which confirmed high-flow left vertebral arteriovenous fistula at C3 to C6 levels with a direct shunt to epidural and paravertebral venous plexus. There was no filling from any other vessels.
The patient underwent endovascular treatment, in which coils were used to trap the involved vertebral artery. The patient tolerated the procedure well, and at 2 months of follow-up, the patient had improvement of the weakness in the left upper limb. The blood pressure of the patient returned to normal just after the procedure.
DiscussionThe second portion of vertebral artery is mostly involved in cases of traumatic injury, whereas the third portion is affected by spontaneous or congenital causes.[6] In cases of penetrating injury, because of the posterior and long intra-foraminal path of the vertebral artery, it is rarely involved.
They are classified as segmental or intersegmental types. In the segmental type, there is a fistula involving a branch of the vertebral artery, whereas in the intersegmental type the fistula involves the vertebral artery itself. Traumatic fistulas are the most common types and are mostly iatrogenic, whereas spontaneous AVF is the least common and is associated with Marfan's syndrome, Ehlers–Danlos syndrome, fibromuscular dysplasia, or neurofibromatosis (NF).[7],[8],[9]
In spontaneous vertebral AVF, the blood is shunted from a vertebral artery or its branches into surrounding veins, such as epidural venous plexus, paravertebral vein, internal jugular vein, and perimedullary vein.[10]
The symptoms in these cases are mostly related to the flow and chronicity of the shunts.[10],[11] Most commonly, they are asymptomatic in nature and are incidentally detected at routine examination for neck pain. Tinnitus can occur due to turbulent flow, and rarely, vertigo can occur due to arterial steal phenomena. Radiculopathy in such patients is due to epidural venous engorgement with venous hypertension from pial venous reflux, resulting in direct spinal cord compression or ischemia due to arterial steal or venous hypertension.
The treatment of vertebral AVF is obliteration of fistula with or without preservation of vertebral artery as in some cases the preservation of vertebral artery is not possible.[12],[13] The patency of the fistula can be maintained by the collaterals from ascending cervical, deep cervical, ascending pharyngeal, or segmental branches of vertebral artery, thus necessitating complete obliteration of the fistula.
Surgical treatment is often difficult and leads to suboptimal ligation because of uncontrollable massive bleed resulting from dilated and engorged veins, injuries to surrounding tissue, and steal flow syndrome.[12] Ligature of fistula using a bypass venous graft is used for large, complex fistula with multiple feeders. Such an approach is no longer taken at present.
The endovascular treatment started with the use of detachable balloons. The endovascular route using a trans-arterial detachable balloon, coils, stents, and ethylene vinyl alcohol (EVOH) or in combinations has become the treatment of choice.[10],[14] Coiling and stents have become popular in recent times; although navigating stents and detachable balloons in patients with fibromuscular dysplasia have tortuous vessels, the optimal treatment in such cases is the sacrifice of the vertebral artery. The liquid embolic agents should not be used alone in large AVF due to the high risk of distal embolic events and can be used only after packing coils. A combination of coils and liquid embolic agents or balloon with coils has been used for the treatment, which has been previously reported by Gao et al.[15] If the AVF flow is low and the fistula is evident at DSA, then coiling of the fistula should be performed, whereas if the point of the fistula is not evident or cannot be cannulated and the fistula had a high flow, with vertebral artery sacrifice tolerable, then a combined approach should be taken up. We used balloon-assisted trans-arterial coil embolization of the fistula with trapping of the vertebral artery in this case.
Post-treatment, there was a good recovery from the symptoms over time.
ConclusionThere are no clear-cut guidelines for the treatment of choice up till now, but balloon-assisted coil embolization of the fistula with trapping of the vertebral artery is a safe, reliable, and cost-effective technique in patients who tolerate balloon occlusion test.
Declaration of patient consent
A full and detailed consent from the patient or guardian has been obtained. The patient's identity has been adequately anonymized. If anything related to the patient's identity is shown, adequate consent has been obtained from the patient, relative, or guardian. The journal will not be responsible for any medicolegal issues arising out of issues related to the patient's identity or any other issues arising from the public display of the video.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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