Hybrid open-endovascular onyx embolization of spinal type IVb perimedullary spinal arteriovenous fistula through direct posterior spinal vein access: A case report.

Surgical neurology international Pub Date : 2024-09-27 eCollection Date: 2024-01-01 DOI:10.25259/SNI_384_2024
Romulo Augusto Andrade de Almeida, Francisco Call-Orellana, Christopher C Young, Franco Rubino, Sara L Thrower, Stephen R Chen, Robert Y North
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Abstract

Background: Spinal arteriovenous fistulas (SAVFs) are direct communication between arteries and veins without intervening abnormal vessel nidus, which often results in venous congestion and spinal cord dysfunction. Ventrally located SAVF can be challenging to treat through traditional open or endovascular approaches.

Case description: We describe a hybrid (open/endovascular) procedure in a 72-year-old male with a Takai Type IVb SAVF presenting with paraparesis and sphincter dysfunction. Imaging revealed a conus medullaris SAVF in which the main fistulous connection was located ventrally. The conventional endovascular approach was deemed risky, and open surgery failed in the first attempt. The SAVF was resolved using a hybrid approach: under direct visualization, an engorged dorsal vein was punctured with an Angiocath, and a fluoroscopy-guided microcatheter was advanced through it to reach and embolize the ventral perimedullary fistulous connection. After surgery, his progressive neurological decline stabilized, radiographic spinal cord edema improved, and follow-up angiography confirmed obliteration of the fistula. Neurological function remained at the preoperative baseline.

Conclusion: This approach may be a treatment for selected cases of type IVb SAVF. Easily accessible feeding vessels are coagulated and cut; the inaccessible ones can be embolized endovascularly during the same procedure.

通过脊髓后静脉直接入路对脊髓Ⅳb型髓内动静脉瘘进行混合开放血管内缟栓塞术:病例报告。
背景:脊髓动静脉瘘(SAVF)是动脉和静脉之间的直接沟通,没有异常血管巢的介入,通常会导致静脉充血和脊髓功能障碍。通过传统的开放或血管内方法治疗位于中心位置的 SAVF 具有挑战性:我们描述了一名 72 岁男性的混合(开放/血管内)手术,他患有高井 IVb 型 SAVF,表现为偏瘫和括约肌功能障碍。影像学检查发现,髓圆锥部有一SAVF,主要瘘管连接位于腹侧。传统的血管内方法被认为有风险,首次尝试开放手术失败。他采用混合方法解决了SAVF问题:在直视下,用Angiocath穿刺充血的背静脉,然后在透视引导下将微导管穿过背静脉,到达腹侧髓周瘘管连接处并将其栓塞。术后,他的神经功能进行性衰退趋于稳定,脊髓水肿的影像学表现有所改善,随访血管造影证实瘘管已被堵塞。神经功能保持在术前基线:结论:这种方法可用于治疗特定的 IVb 型 SAVF 病例。在同一手术过程中,凝固并切断容易进入的供血血管,并对无法进入的供血血管进行血管内栓塞。
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