Glue Embolization with Guide Catheter Dextrose Push of Recurrent Dural Arteriovenous Fistula Previously Embolized...

Onyx (ethylene vinyl alcohol, ev3, Irvine, California, USA) is commonly used to treat dural arteriovenous fistulas (DAVFs) and presents several advantages over n-butyl cyanoacrylate glue (Codman Neurovascular Inc, Raynham, Massachusetts, USA) including slower, more controlled injections and better penetration via radial casting. However, Onyx is nonthrombogenic and may result in incomplete casting, recanalization, and DAVF recurrence. Here, we demonstrate glue embolization with guide catheter dextrose push of a recurrent DAVF previously embolized with Onyx. A 79-year-old female diagnosed with a Cognard IIA+B DAVF was successfully treated with transarterial Onyx injection. A 6-month follow-up angiogram, however, revealed recurrence of the DAVF with recanalization of the previously embolized draining vein. She subsequently underwent retreatment using glue embolization with a guide catheter dextrose push. Informed written consent was obtained. A Magic microcatheter (Balt Extrusion, Irvine, California, USA) was passed via a 6-French Envoy guide catheter (Codman Neurovascular) in the external carotid artery and was used to select the superficial temporal artery and then navigated distally through a transosseous connection into the dura. A dilute 12.5% concentration of glue was injected slowly and continuously and was seen to fill in spaces within the old Onyx material. Dextrose 5% in water was concomitantly injected through the guide catheter to ensure distal migration of the glue and occlusion of the draining vein. Glue embolization with dextrose push is a valuable treatment option for DAVF, especially in smaller recurrent feeders that can fill in the Onyx recanalized cast. The 6-month follow-up angiogram showed persistent occlusion of the dural fistula (Video 1).