Strategies for embolization of direct arteriovenous shunts in brain arteriovenous malformations

Abstract

Intranidal direct arteriovenous (AV) shunts are rarely observed in brain arteriovenous malformations (bAVMs).1 The endovascular treatment of such direct AV shunts may be challenging. Indeed, there is a significant risk of venous migration of the embolic agent used to occlude the AV shunt, leading to a subsequent risk of nidus bleeding due to impairment (slowdown or even occlusion) of the bAVM’s venous drainage.2Various endovascular techniques have been developed to avoid the risk of such inopportune impairment of the venous drainage during attempts to occlude a direct intranidal AV shunt.3–5 We present in this Technical Video (video 1) different endovascular strategies to occlude such direct AV shunts using dual-lumen balloons with various liquid embolic agents, or using occlusion plugs.Video 1

Endovascular Management of Brain Arteriovenous Malformations

“…Highly concentrated NBCA combined with an additional flow arrest approach (coils, balloon, etc.) may be used to occlude direct high flow fistulas (75).…”

“…may be used to occlude direct high-flow fistulas. 73 If the venous compartment is intact, the arterial approach has the benefit of enabling partial embolization and several sessions of EVT without running the risk of additional bAVM hemorrhage. On the other hand, the primary restriction of pure arterial access is the impossibility to obtain a complete filling of the nidus due to the lack of a suitable feeder ("en passant," extra-small or distal; absence of safety margins for reflux), as well as the absence of LEA penetration (►Fig.…”