Transvenous embolization with a combination of detachable coils and Onyx for a complicated cavernous dural arteriovenous fistula.

Abstract

Treatment of cavernous dural arteriovenous fistulas (DAVF) is usually made by a transarterial approach. However, in many complicated patients, treatments via transarterial approaches can not be achieved, and only an operation via a transvenous approach is feasible. We aimed to study the feasibility of transarterial embolization of cavernous dural arteriovenous fistulas with a combination detachable coils and Onyx to embolize a complicated cavernous DAVF via a transvenous approach.
From August 2006 to August 2007, six cases of complicated cavernous DAVF were embolized with a combination of detachable coils and Onyx via a transvenous approach. Three cases were male and the other three were female. Their ages ranged from 36 to 69 years old. The fistula was in the right lateral cavernous sinus in one case, in the left lateral cavernous sinus in another, and in the bilateral cavernous sinus in 4 cases. One fistula was fed by the right internal carotid artery and its meningohypophyseal trunk; one was fed by the branches of the left internal carotid artery and left external carotid artery; four were fed by the branches of the bilateral internal carotid artery and/or the bilateral external carotid artery. One case was drained via one lateral inferior petrosal sinus; three were drained via bilateral inferior petrosal sinuses; one was drained via one lateral ophthalmic and facial veins; one was drained via the inferior petrosal sinus and the ophthalmic and facial veins. Four were embolized via the inferior petrosal sinus, and two were embolized via the ophthalmic and facial veins.
Among six cases of complicated cavernous DAVF, four were fully embolized with Onyx by a single operation, and two cases were fully embolized with Onyx following two operations. Transient headache was found after operation in all patients, but was cured after several days by the symptomatic treatments. In one case, the first operation via the inferior petrosal sinus was a failure; the feeding branches of the external carotid artery were embolized, and transient facial palsy was appeared after operation. The fistula was fully embolized with Onyx via the inferior petrosal sinus after two months with no complications. One bilateral cavernous sinus DAVF was embolized with Onyx via the inferior petrosal sinus by two operations, and transient abducens nerve palsy occurred after embolization.
Because Onyx may be injected via a transvenous approach and the microcatheter is easily withdrawn, cavernous sinus via transvenous catheterization and embolization is a safe and efficient way to treat complicated cavernous dural arteriovenous fistulas, especially those for which operations via transarterial approaches have failed, or spontaneous cavernous dural arteriovenous fistulas.

Full text

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Chinese Medical Journal 2008; 121(17):1651-1655
1651
Original article

Transvenous embolization with a combination of detachable coils
and Onyx for a complicated cavernous dural arteriovenous fistula

HE Hong-wei, JIANG Chu-han, WU Zhong-xue, LI You-xiang, LÜ Xian-li and WANG Zhong-cheng

Keywords: transvenous; cavernous dural arteriovenous fistula; embolization; Onyx; detachable coils

Background Treatment of cavernous dural arteriovenous fistulas (DAVF) is usually made by a transarterial approach.
However, in many complicated patients, treatments via transarterial approaches can not be achieved, and only an
operation via a transvenous approach is feasible. We aimed to study the feasibility of transarterial embolization of
cavernous dural arteriovenous fistulas with a combination detachable coils and Onyx to embolize a complicated
cavernous DAVF via a transvenous approach.
Methods From August 2006 to August 2007, six cases of complicated cavernous DAVF were embolized with a
combination of detachable coils and Onyx via a transvenous approach. Three cases were male and the other three were
female. Their ages ranged from 36 to 69 years old. The fistula was in the right lateral cavernous sinus in one case, in the
left lateral cavernous sinus in another, and in the bilateral cavernous sinus in 4 cases. One fistula was fed by the right
internal carotid artery and its meningohypophyseal trunk; one was fed by the branches of the left internal carotid artery
and left external carotid artery; four were fed by the branches of the bilateral internal carotid artery and/or the bilateral
external carotid artery. One case was drained via one lateral inferior petrosal sinus; three were drained via bilateral
inferior petrosal sinuses; one was drained via one lateral ophthalmic and facial veins; one was drained via the inferior
petrosal sinus and the ophthalmic and facial veins. Four were embolized via the inferior petrosal sinus, and two were
embolized via the ophthalmic and facial veins.
Results Among six cases of complicated cavernous DAVF, four were fully embolized with Onyx by a single operation,
and two cases were fully embolized with Onyx following two operations. Transient headache was found after operation in
all patients, but was cured after several days by the symptomatic treatments. In one case, the first operation via the
inferior petrosal sinus was a failure; the feeding branches of the external carotid artery were embolized, and transient
facial palsy was appeared after operation. The fistula was fully embolized with Onyx via the inferior petrosal sinus after
two months with no complications. One bilateral cavernous sinus DAVF was embolized with Onyx via the inferior petrosal
sinus by two operations, and transient abducens nerve palsy occurred after embolization.
Conclusions Because Onyx may be injected via a transvenous approach and the microcatheter is easily withdrawn,
cavernous sinus via transvenous catheterization and embolization is a safe and efficient way to treat complicated
cavernous dural arteriovenous fistulas, especially those for which operations via transarterial approaches have failed, or
spontaneous cavernous dural arteriovenous fistulas.
Chin Med J 2008;121(17):1651-1655

O
nyx (Micro Therapeutics. Inc., Irvine, CA, USA) is a
liquid embolic material designed for endovascular
use. It is a biocompatible polymer (ethylene-vinyl alcohol
copolymer; EVOH) dissolved in organic solvent,
dimethyl sulfoxide (DMSO). The EVOH is composed of
a random mixture of two subunits: ethylene (hydrophobic)
and vinyl alcohol (hydrophilic). Micronized Tantalum is
pre-mixed for radiopacity. When this mixture contacts a
liquid agent, such as blood, DMSO rapidly diffuses away
from the mixture, causing in situ precipitation and
solidification of the polymer. The liquid agent becomes
spongy and occlusive without adhering to the vascular
wall. It is handled easily and appears to be an effective
and safe agent for embolization of cerebral arteriovenous
malformations.1

Dural arteriovenous fistula is characterized by abnormal
communication between the arteries supplying the dura
and the cerebral venous sinus,2 which often occurs in the
lateral/sigmoid sinus and cavernous sinus.3 Traditionally,
cavernous dural arteriovenous fistula is treated via a
transarterial approach with NBCA, silk, detachable
balloon and coils, or is embolized via a transvenous
approach with coils.4-8 However, complicated or
spontaneous cavernous dural arteriovenous fistulas
(DAVFs) usually involve the bilateral cavernous sinus
with a bilateral arterial supply; thus, embolization
treatment via transarterial or transvenous approaches with
coils can not cure, but only relieve the symptoms,
treatment is expensive, the operations are more difficult,
and operation time is longer. From August 2006 to August
Department of Neuroradiosugery, Beijing Neurosurgery Institute,
Beijing Tiantan Hospital, Capital Medical University, Beijing
100050, China (He HW, Jiang CH, Wu ZX, Li YX, Lü XL and
Wang ZC)
Correspondence to: Dr. HE
Neuroradiosugery, Beijing Neurosurgery Institute, Beijing Tiantan
Hospital, Capital Medical University, Beijing 100050, China (Tel:
86-13581775788. Email: ttyyhhw@gmail.com)

Hong-wei, Department of

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microcatheter was pushed into the right cavernous sinus via the inferior petrosal sinus. D: Two microcoils were inserted into the right
cavernous sinus. E: Injecting Onyx-34 into the right cavernous sinus (3 ml), the fistula was embolized successfully (arrow). F, G:
Angiography of the right/left internal carotid artery (anterior view) after Onyx embolization showing that the DAVF had vanished.

2007, six patients with complicated cavernous DAVFs
were treated with a combination of detachable coils and
Onyx via transvenous approaches in our hospital.

METHODS

Patients
Three cases were male and the other three were female.
Their ages ranged from 36 to 69 years. The mean age was
51 years old. All of them had headaches and ocular
symptoms, including blepharoptosis, diplopia, conjunctive
congestion, exophthalmos, visual disturbance. In one case,
cerebellar hemorrhage occurred before embolization.

Cerebral angiography
Feeding artery
In one case, the fistula was fed by the right internal
carotid artery and its meningohypophyseal trunk; in
another, the fistula was fed by the branches of the left
internal carotid artery and the left external carotid artery;
in four cases, the fistulas were fed by the branches of the
bilateral internal carotid artery and/or bilateral external
carotid artery.

Draining vein
In one case the fistula was drained via one lateral inferior
petrosal sinus; in three, the fistulas were drained via the
bilateral inferior petrosal sinuses; in another, the fistula
was drained via one lateral ophthalmic vein-facial vein;
and in another, the fistula was drained via the inferior
petrosal sinus and the ophthalmic vein-facial vein.

Treatments
The cavernous sinuses were embolized with a
combination of detachable coils and Onyx. In four cases
the fistulas were embolized via a femoral vein-inferior
petrosal sinus approach, and in two cases the fistulas were
embolized via a femoral vein-facial vein-superior
ophthalmic vein approach.

Femoral vein-inferior petrosal sinus approach
Four cases were embolized with Onyx via this approach.
Catheter sheaths (6F) were placed into both the left and
right femoral arteries. Then, angiography was performed
via the common carotid artery or the external carotid
artery in the diseased side with a 5F catheter. Through the
femoral vein approach, a 6F or 5F guided catheter (Envoy
or FAS Guide) was placed via the exchange wire in the
unilateral internal jugular vein near the glomus jugulare
on the lesion side. Afterwards, a microcatheter
(Echelon-10) with microwire (Silverspeed-10 or Synchro)
was pushed into the involved cavernous sinus via the
inferior petrosal sinus. Then, the cavernous sinus was
embolized with Onyx-18 or Onyx-34 under the road map.
During embolization, angiography was performed
continuously to evaluate the therapeutic effect. When
DAVFs disappeared under angiography, the operations
ceased. If the treatment costs are enough, the coils can be
embolized into the cavernous sinus near the ophthalmic
vein opening before injecting Onyx. This may prevent
Onyx from flowing into the ophthalmic vein and causing
ocular complications (Figure 1).

Femoral-facial-superior ophthalmic vein approach
Two cases were embolized with Onyx via this approach.
Catheter sheaths (6F) were placed into both the left and
right femoral arteries. Then, angiography was performed
via the common carotid artery or external carotid artery in
the diseased side with a 5F catheter. Through a femoral
vein approach, a 6F or 5F guided catheter was placed via
the exchange wire in the unilateral internal jugular vein
near the proximal end of the facial vein. In some cases,
Figure 1. Onyx embolization of
a cavernous dural arteriovenous
fistulas (DVAF) via a femoral
vein-inferior petrosal
approach (right spontaneous
DAVF). A, B: Angiography of
the right/left internal carotid
artery (anterior view) before
embolization showing that the
DAVF drains into the bilateral
inferior petrosal sinus (arrow
heads) and fistula (arrow). C: A
sinus

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Figure 2. Onyx embolization of a cavernous dural arteriovenous fistulas (DAVF) via a femoral-facial-superior ophthalmic vein approach
(right spontaneous DAVF). A: MRA showing right DAVF (arrow) B: Angiography of the right common carotid artery (lateral view)
before embolization showing that DAVF drains into the superior ophthalmic vein and facial vein (arrow heads) and fistula (arrow). C:
Angiography of the left common carotid artery (anterior view) before embolization showing that the DAVF drains into the right lateral
inferior petrosal sinus (arrow) and fistula (arrow). D: Microcatheter arriving in the right cavernous sinus via the facial vein and superior
ophthalmic vein (arrow heads). E: Eight microcoils were pushed into the right cavernous sinus. F: Injecting Onyx-18 into the right
cavernous sinus (2 ml), the fistula was embolized successfully (arrow head). G, H: Angiography of the right/left common carotid artery
(anterior view) after Onyx embolization showing that the DAVF had vanished.

the guided catheter was placed into the external jugular
vein. Afterwards, the microcatheter with microwire was
pushed into the involved cavernous sinus via the
facial-superior ophthalmic vein approach. The emboli-
zation process was as mentioned above (Figure 2).

Follow-up
The patients were usually discharged 3 days after
embolization if there were no related neurological
complications. The first angiographical follow-up was
recommended to be 3 months post-operation. If the
disease recurred or neurological complications appeared,
angiography was set up at once. Transvenous approach
embolization was restarted if necessary. The second
angiographical follow-up was at 6 months post-operation.
If needed, a third angiographical follow-up could be
performed 1 year post-operation.

RESULTS

In six cases of complicated cavernous DAVF, the
cavernous sinus was embolized by a combination of
detachable coils and Onyx. Four were fully embolized
with Onyx by a single operation, and two were fully
embolized with Onyx by two operations. Transient
headache was found after operation in all patients, but
was cured after several days by the symptomatic
treatments. In one case, the first operation via the inferior
petrosal sinus failed; the feeding branches of the external
carotid artery were embolized, and transient facial palsy
appeared after operation. The sinus was fully embolized
with Onyx via the inferior petrosal sinus after two months
with no complications. One bilateral cavernous sinus
DAVF was embolized with Onyx via the inferior petrosal
sinus by two operations, and transient abducens nerve
palsy occurred after embolization, which recovered later
without treatment.

All patients were cured without recurrence during
follow-up. Follow-up angiography of two patients was
performed in our hospital; follow-up of four patients was
performed in another hospital. The six cases have been
followed up for six months to one year, and no
complications have occurred.

DISCUSSION

Dural arteriovenous fistula treatment history
DAVF is characterized by abnormal communication
between the arteries supplying the dura and the cerebral
venous sinus. Surgical ablation is difficult because the
blood-supply to such fistulas is wide, the supply arteries
are thin, circuitous and complicated, the draining veins
may be antrorse or retrorse, and there may be one or
multiple fistulas. Treatments for DAVF have changed
with the development of image documentation equipment
and embolism materials. When the embolism materials
were silks, beads, NBCA, and free coils, the treatment
effectiveness was poor.9 Recently, some DAVFs have
been fully embolized with controllable coils via

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transarterial approaches, transvenous approaches, or the
two approaches together. However, full embolization
requires a lot of coils, the treatment is expensive, and
many patients cannot afford the treatment. Many DAVF
patients have several fistulas and the microcatheter
cannot reach every fistula, so many DAVF patients cannot
be cured.10

Onyx for non-adhesive liquid embolism
Onyx (Micro Therapeutics. Inc.) is a liquid embolic
material designed for endovascular use. It is a
biocompatible polymer
copolymer; EVOH) dissolved in organic solvent, DMSO.
Micronized Tantalum is pre-mixed for radiopacity. It is
easily handled, injection time long, and does not adhere
to the microcatheter. It has been an effective and safe
agent for embolization of cerebral arteriovenous
malformation since it came to our country in 2003.1
DAVF embolization with Onyx via transarterial
approaches has been used with good clinical effect in our
hospital for several years. This embolization method has
also been used in other countries.11,12 There are several
types of Onyx, according to EVOH density. Onyx-18 and
Onyx-34 may be used to embolize cerebral arteriovenous
malformations and DAVFs, Onyx-500 is used to
embolized intracranial aneurysms because of its high
density.13-16

Complicated cavernous DAVFs
Complicated cavernous DAVFs are characterized by
abnormal communication between the arteries supplying
the dura and the cavernous sinus. The arterial blood
comes into the cavernous sinus, and undergoes backward
flow into the ophthalmic vein. This raises the pressure of
the ophthalmic vein, and leads to eye symptoms. The
clinical manifestations of patients with complicated
cavernous DAVFs are related to the direction of venous
drainage and blood flow through the arteriovenous
fistula.17,18 Patients with drainage via the ophthalmic vein
often show severe ophthalmic symptoms, including
blepharoptosis, diplopia,
exophthalmos, visual disturbance, while those with
drainage through the dermal epithelium vein or cortical
venous reflex (CVR) usually have local nerve
dysfunction, and are at risk of intracranial hemorrhage.
The hemorrhage rate is 17%–24%.19-24 Patients with CVR
should be treated with Onyx as soon as possible,25 as 35%
of patients will have intracranial hemorrhages, 30% of
cases will develop nerve dysfunction, and 45% of patients
will die.26 Our study showed that six patients with
complicated cavernous DAVFs all had different degrees
of headache and the above-mentioned eye symptoms; and
one case had cerebellar hemorrhage.

Selection of a transvenous approach or transarterial
approach
When the branches of the internal carotid artery have
blood to supply a fistula, the Onyx flow route and volume
must be controlled, preventing Onyx from flowing into
the internal carotid artery and causing severe
(ethylene-vinyl alcohol
conjunctive congestion,
complications.27 These complications include hemiplegia,
transient visual loss, cranial nerve symptoms, and even
death. Because DAVF is a kind of complicated
cerebrovascular disease, it can not be cured by only one
treatment approach. There must be a therapeutic alliance
between transvenous and transarterial approaches at times.
The embolism materials also combine Onyx with coils. In
one of our cases, some supplying arteries were embolized
with coils, and made blood flow reduce via a transarterial
approach; then, the fistula was embolized with Onyx via a
transvenous approach.

In the clinic, the first option is to operate via a
transarterial approach. If a transarterial approach is likely
to be difficult, the microcatheter can not reach the fistula,
or the draining vein is obvious, a transvenous approach
may be used. Embolization of complicated cavernous
DAVFs with Onyx via a transvenous approach may result
in better clinical effect. Its greatest index is that the fistula
is embolized by Onyx, and its fistula, supplying arteries,
and draining vein are nonvisualization.28 This treatment
method has not been widely reported. Our six cases
treated with this method all recovered well.

Comparison of the two venous approaches
There were no marked differences in the operation
techniques, therapeutic efficacy or complication rates
between the two transvenous approaches. The choice
between the two approaches was not tendentious.
According to image of the facial vein and inferior
petrosal sinus, the approach of entering the cavernous
sinus was an easy choice. When one approach could not
succeed, the other would be selected. In a clinical process,
an approach via the femoral vein-inferior petrosal sinus is
safer and more convenient than an approach via the
femoral vein-facial vein-superior ophthalmic vein. Thus,
it is the first method of choice between the transvenous
approaches. When a femoral vein-inferior petrosal sinus
approach is unsuccessful, a
vein-superior ophthalmic vein approach is used.
Cavernous dural arteriovenous
successfully treated by transvenous embolization via
different venous routes. If the fistula is large, and blood
from the draining vein is flowing quickly, some coils may
be embolized into the cavernous sinus before injecting
Onyx. If the blood flow is slow, the Onyx may not be
washed away, and can not lead to abnormal embolism
position.22 Among our six cases, all cases had coils
embolization before injection of Onyx. Four fistulas were
embolized with Onyx via a femoral vein-inferior petrosal
sinus approach, and two cases were embolized via a
femoral-facial-superior ophthalmic vein approach. All
patients were cured and there were no severe
complications.

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and dural arteriovenous
RA. Venous congestive
of cavernous dural
(Received April 15, 2008)
Edited by LIU Dong-yun