PMC9990773_01
Angiography images (a-e) and ]schematic diagram (f) of the dural arteriovenous fistula (a and b) frontal and lateral view of the left external carotid angiography images showing a dural arteriovenous fistula near the anterior condylar confluence with outflow to the jugular vein and no backflow to the sinus or cortical vein. (c) A coronal view of cone-beam computed tomography reconstructed from 3D-rotational angiography (3D-RA) through the left external carotid artery showing the fistula (arrow) within the bone superomedially to the hypoglossal canal (yellow line), just under the jugular tubercle. (d and e) 3D-RA images showing a shunt pouch (green) in the bone near the hypoglossal canal (yellow), which drains into the jugular vein (blue). (f) A schematic diagram shows that several feeders (red arrows and dashed arrow) are flowing into a shunt pouch located within a bone near the hypoglossal canal.
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F1
The shunt pouch was located in the JTVC, near the left hypoglossal canal, with feeders from the bilateral ascending pharyngeal arteries and occipital arteries, left meningohypophyseal trunk, and odontoid arch of the left vertebral artery [Figures 1a-d]. The patient was diagnosed with a Cognard type I and Borden type I dAVF with a shunt at the JTVC [Figures 1e and f].
Endovascular treatment of dural arteriovenous fistula (a-d) and postoperative imaging (e-h) (a) Working angle view of the left external carotid angiography through a 4 Fr. guiding sheath (as seen in panel c: *) showing a dural arteriovenous fistula. (b and c) A microcatheter (single arrowhead) is guided to the shunt point using a 45  pre-shaped distal access catheter (double arrowhead) through a 6 Fr guiding sheath (triple arrowhead) which is placed in the left internal jugular vein. Another 6 Fr guiding sheath (double arrow) is also placed in the left internal jugular vein to guide a balloon catheter (single arrow) near the shunt. (d) The balloon catheter is inflated to support the microcatheter and to avoid deviation of the coil to the jugular vein. Coiling into the shunt pouch is performed through the catheter. (e and f) Axial and coronal view from cone-beam computed tomography images showing the detachable coils implanted in the shunt pouch within the bone. (g and h) Frontal and lateral view of the left external carotid angiography showing that the shunt is completely occluded.
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F2
TVE was performed near the shunt pouch [Figure 2]. Asahi Intecc, Aichi, Japan) was inserted into the left external carotid artery through the left femoral artery, and a 6 Fr guiding sheath (Axcelguide; Medikit, Tokyo, Japan) was placed in the left internal jugular vein through the right femoral vein after administration of 4000 units of intravenous heparin. A microcatheter (Excelsior SL-10 45; Stryker, Michigan, USA) was guided to the shunt point using a 45  pre-shaped distal access catheter [Figure 2a]. In addition, another 6 Fr guiding sheath (Flexor Shuttle; Cook Medical, Bloomington, IN, USA) was inserted into the left internal jugular vein through the left femoral vein [Figures 2b and c]. A balloon catheter (SHOURYU HR 7/7; Kaneka Medix, Osaka, Japan) was inflated in the left internal jugular vein near the shunt, and coiling was performed through the microcatheter into the shunt pouch [Figure 2d]. Subsequently, four additional detachable coils were implanted in the shunt pouch, and a total coil insertion of 17 cm was required to occlude the shunt completely [Figures 2e-h].