Retrograde transvenous coil embolization in spinal epidural arteriovenous fistula with radiculo-perimedullary reflux

Spinal epidural arteriovenous fistulas (SEAVFs) with intradural reflux are rare but important vascular lesions that may cause progressive myelopathy due to spinal cord venous hypertension. Although traditionally managed by means of arterial embolization or surgical disconnection, these approaches can pose risks, particularly when critical vascular structures, such as the artery of Adamkiewicz, originate in close proximity to the fistulous site. We report the case of a patient in their 60s who presented with progressive paraparesis over approximately 1 year, ultimately attributed to an SEAVF located adjacent to the right L1-L2 neural foramen, with radiculo-perimedullary reflux. The artery of Adamkiewicz was visualized with its origin near the shunt site, rendering arterial embolization unsafe and prompting selection of a purely transvenous endovascular approach. Venous access was obtained via the azygos system, and a microcatheter was navigated through the epidural venous pouch to reach a cranially directed draining vein extending toward the perimedullary venous system, which was then embolized using detachable platinum coils. The procedure achieved complete occlusion of the targeted vein, with early neurological improvement and significant reduction in spinal cord edema on follow-up imaging. This case supports the feasibility, safety, and efficacy of transvenous embolization for SEAVFs and underscores its expanding role in the treatment of complex spinal vascular lesions.