Transvenous Retrograde Pressure Cooker Technique for Embolization of a Tentorial Dural Arteriovenous Fistula Draining into the Superior Petrosal Vein.

OBJECTIVE: A tentorial dural arteriovenous fistula (DAVF) draining into the superior petrosal vein, also referred to as a petrous DAVF, is a Borden type 3 lesion with an aggressive natural history. Standard treatment options include surgical disconnection of the drainer or transarterial embolization (TAE). While the former requires an invasive craniotomy, the latter is associated with incomplete occlusion and a high complication rate. Transvenous embolization (TVE) has traditionally been considered challenging. We report a case of TVE performed through a tortuous pial vein using the retrograde pressure cooker technique (RPCT).

CASE PRESENTATION: A 38-year-old woman presented with right pulsatile tinnitus. Angiography revealed a petrous DAVF supplied by the petrous branch of the middle meningeal artery, the ophthalmic artery, and the inferolateral trunk. A TAE attempt failed due to the narrow and tortuous access of the eloquent feeder. Consequently, TVE was performed via right jugular access, with retrograde navigation of 2 microcatheters through the vein of Galen, basal vein of Rosenthal, and lateral mesencephalic vein. After coils were placed as a plug scaffold in the draining vein, Onyx 34 (Medtronic, Irvine, CA, USA) was injected under intentional systemic hypotension. This resulted in the occlusion of the foot of the drainer, the fistulous point, and the feeders adjacent to the fistula. Due to the significant resistance encountered and the associated risk of venous injury, the microcatheter used for Onyx injection was left in place. The patient's symptoms resolved completely without any neurological deficit.

CONCLUSION: TVE using the RPCT achieved complete obliteration of a petrous DAVF. Further cases are needed to validate the feasibility and safety of this technique.