Selective embolization of an uncatheterizable trans-osseous feeder using a dual-balloon pressure cooker technique: technical note.

BACKGROUND

Embolization of dural arteriovenous fistulas (dAVFs) supplied by tortuous trans-osseous occipital artery (OA) feeders remains challenging when distal catheterization is not achievable and competing runoff diverts Onyx from the fistulous connection. We describe a novel dual-balloon flow-isolation technique.

CASE DESCRIPTION: A 79-year-old woman with a Cognard type IV transverse sinus dAVF presented with cognitive decline, headache, and pulsatile tinnitus. Angiography demonstrated tortuous trans-osseous OA feeders converging on a fistulous connection with cortical venous reflux and a venous varix. Following unsuccessful feeder catheterization, two Scepter Mini balloon microcatheters were positioned within a single OA pedicle. Proximal and distal flow arrest selectively isolated a single feeding vessel, permitting forceful injection of diluted Onyx. Onyx traversed the trans-osseous feeders, crossed the fistulous connection, and filled the draining vein and venous varix, achieving complete angiographic obliteration without complications.

CONCLUSIONS

Dual-balloon flow isolation may facilitate curative embolization when distal catheterization is not feasible and competing runoff limits Onyx penetration.