Transumbilical access for neonatal vein of Galen malformation and pial arteriovenous fistula embolization.

Background: In the neonatal period, transfemoral access may be complicated by sheath size needed for embolization, especially if retreatment is required. A viable alternative is access through an umbilical artery (UA) which allows for preservation of the femoral artery for access in future intervention.

Methods: We conducted a retrospective study from January 2014 to March 2023, focusing on 19 vein of Galen malformation, dural arteriovenous (AV) fistula, and pial AV fistula cases treated via transumbilical (TU) access for endovascular embolization in neonates.

Results: TU access was achieved successfully in 20 out of 21 intended cases, with a 4 French sheath placed intraprocedurally in all instances. We observed a median retreatment time of 7 months for patients requiring subsequent femoral artery access, highlighting the importance of preserving femoral access for future interventions. There were no complications associated with TU access or sheath retention and no procedural mortality attributed to this approach. Despite intraprocedural and periprocedural complications of other etiologies (including post-procedural hemorrhages and fever requiring antibiotic treatment), the TU approach demonstrated overall safety and efficacy.

Conclusions: Our findings align with previous reports of TU access in vascular malformations, emphasizing its role as a vital technique in neonatal neurointervention. The TU approach offers advantages such as sparing femoral arteries for future treatments and potential applicability to other high-flow brain fistulas. Our study contributes to the growing body of evidence supporting the use of TU access in neonatal neuroendovascular interventions, underscoring its importance in managing complex vascular malformations in this vulnerable population.