Biplane 3D roadmap-guided traversal of an occluded sinus for transvenous embolization of a TS-SS/marginal sinus dAVF

Isolated sinus dural arteriovenous fistulas (dAVF) with cortical venous reflux are associated with a high risk of intracranial hemorrhage.1 Although transarterial embolization using Onyx is a common treatment strategy, transvenous embolization through an occluded sinus may be necessary when an appropriate arterial access route is unavailable.2-4 However, precise traversal of the occluded segment remains technically challenging. In this technical video, we demonstrate a biplane 3D roadmap technique for accurate traversal of an occluded sinus. The occluded venous sinus was segmented using contrast enhanced MRI and overlaid onto live fluoroscopic images, allowing precise guidance through the occluded segment. Previous reports have demonstrated the usefulness of 3D roadmap guidance for crossing occluded lesions; however, its application to the venous sinus has been limited.5 6 This method could provide a more reliable strategy for transvenous embolization in selected cases. The procedure is demonstrated in video 1neurintsurg;jnis-2026-025565v1/V1F1V1Video 1.