A Case of Spontaneous High-flow Vertebral Arteriovenous Fistula Treated by Trans-arterial Target Embolization Using Balloon Remodeling Technique

Abstract

Objective: Spontaneous vertebral arteriovenous fistula (VAVF) is a rare vascular disorder. Herein, we report a case of high-flow VAVF with ipsilateral persistent primitive trigeminal artery (PPTA) treated by trans-arterial target embolization (TE) using balloon remodeling technique (BRT). Case Presentation: A 58-year-old woman with a medical history of non-tuberculous mycobacterial lung disease had complained of right-sided pulsatile tinnitus for 3 years; however, there were no symptoms due to brain or spinal cord dysfunction. DSA revealed high-flow VAVF in the right V3 segment at the C2 vertebral body level and ipsilateral PPTA. The multi-planar reconstruction (MPR) images of cone-beam CT (CB-CT) obtained from 3D rotational angiography (3D-RA) in the arterial phase were useful to evaluate the morphology of VAVF. The fistula was single and positioned in the V3 segment at the C2 vertebral body level. The venous side of the fistula had expanded into a spheroid-like shape. A planned trans-arterial TE was performed 39 months after diagnosis due to recurring lung hemorrhage. Using BRT, TE was successful by packing back from the spheroid-like space with coils. The spheroid-like space was located slightly caudal to the fistula, and occlusion balloon inflated just distal to the fistula was helpful to navigate the microcatheter. After 12 months, DSA showed no recurrence of VAVF. Conclusion: The MPR images of CB-CT obtained from 3D-RA were useful for evaluation of the morphological structure of VAVF. The BRT was useful for successful TE.