1052. Combined Transarterial and Transvenous Onyx Embolization of a High-Flow Pial Arteriovenous Fistula of the Temporal Lobe with Multiple Fistulous Connections

Authors: Dale Ding, MD; Rami Almefty, MD; Jacob Baranoski, MD; Joshua Catapano, MD; Gabriella Paisan, MD; Daniel Cavalcanti, MD, PhD; Vance Fredrickson, MD; Andrew Ducruet, MD; Felipe Albuquerque, MD (LOUISVILLE, KY)

Introduction: Pial arteriovenous fistulas (PAVF) of the temporal lobe with purely cortical arterial supply and venous drainage are exceptionally rare vascular lesions without a clearly defined treatment strategy. Methods: We describe our endovascular technique for staged transarterial (Stage 1 with balloon assistance) and transvenous (Stage 2) curative embolization of a high-flow, multi-channel PAVF of the temporal lobe. Results: A 68 year-old woman was incidentally diagnosed with a high-flow PAVF of the right temporal lobe supplied by the anterior temporal artery (ATA) branch of the MCA and two distal branches of the PCA, with venous drainage into an inferior temporal cortical vein, which eventually drained into the transverse sinus. In stage 1, we navigated an Apollo detachable-tip microcatheter into the right ATA, with a partially occlusive 5x20 mm HyperGlide balloon positioned proximally in the artery. The PAVF was partially embolized from this transarterial approach using Onyx 18. In stage 2, we navigated an Apollo microcatheter through the contralateral transverse sinus into the superior sagittal sinus, vein of Trolard, and eventually into the temporal draining vein. Transvenous embolization using Onyx 18 cured the residual PAVF. Post-embolization angiography at four months follow-up showed no evidence of residual or recurrent arteriovenous shunting. The patient was asymptomatic at follow-up (modified Rankin Scale 0). Conclusion: Since multi-channel PAVFs may be difficult to cure from transarterial embolization alone, transvenous approaches should also be considered for these complex lesions. Balloon assistance can be useful for altering the local hemodynamics of a high-flow arteriovenous shunt, thereby improving the control of embolysate delivery.