New fistulas in dura after embolisation

Hello,
I have had tremendous support over the past year through this forum as my husband had an embolisation of fistula in the dura. The surgery was through the femoral artery and was successful.

However it seems that in the last angiogram, they found smaller channels associated with the larger fistula, that needs to be closed off.

Doctors are recommending that they embolise through an external puncture rather than through the artery.

Any thoughts or information on this procedure?

Thank you all.

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It might be that the access they would otherwise want has been closed off by the previous embolization, so the options to go the same way might not be there.

That it is a dural fistula means it is very much on the surface, so no brain to “mash through” (as @JD12’s doctor so nicely put his treatment plan!) so less likely to do damage as part of the operation in that way than for some circumstances.

These things are always frightening. How do you and hubby feel about it?

Very best wishes,

Richard

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Dear Richard,

I think that explanation holds good and we will have a discussion on 6th June where we will be brief about the actual procedure.
Hubby is strangely nervous (he is usually unflappable and optimistic) and this time round, I seem more upbeat ( I am usually the catatrophising person☺️).
Lets see what the surgeon has to say and will update you then. Thank you for responding to my message, really appreciate the speed.

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I hope we are helping you through reading about things here, which could be why you’re more ok about it than him. Like you say, see what the reasons are with the doc and that should help.

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Where is he being treated, if I may ask?

This neurosurgery is a science, but not an exact science

And, I can definitely relate to his anxiousness about it

So far, this is the first case I am hearing of being done through an external entry for an embolization. But, like what Richard said is spot on - there might be no other way in after the 1st round

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Hi Mike,

He is being treated at the National Institute of Neurology & Neurosurgery in London, UK.

We know nothing about this procedure and hopefully will have more information on the 6th.

Thanks for the reply.

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Oh, you are and indirectly supporting my husband too. :pray:t4:

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See what they say.
Sometimes there are anatomical reasons for choosing one access route over another, eg venous or arterial approach depending on the anatomy.
Queens square are a great centre of excellence.

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Hello,

An update after our meeting with the Consultant.

We met with the INR consultant who has advised us that there are 2 channels that need to be embolised. As the artery route is complex he plans to go via the skull through a rare procedure - per cutaneous puncture - Unique percutaneous direct puncture technique for occlusion of a hypoglossal canal dural arteriovenous fistula - PubMed. This, he said, was safe, relatively low risk procedure.

Dr Adam Rennie, is the consultant who will do the procedure.(https://www.dradamrennie.com). He has performed this on one other person, unsuccessfully and says that there is no one else in the UK with this expertise. Risks are minimal it seems with success rates between 50-60%. If they fail to embolise they will consider craniotomy.

When first diagnosed we were told it was simple, nothing to worry about and here we are with a possibility of a craniotomy looming ahead. It is a worrying development!

I need to read more but

needle punctured percutaneously at the hypoglossal foramen

this looks like he’d be going through an existing hole in the skull, so no drilling of holes required, which is rather nice. I’m sure a foramen is a hole.

And in the article, it references transarterial and transvenous approaches having been used before (so the reason for going percutaneously is it is the last embolization route available other than craniotomy).

When you say his previous patient was unsuccessful, I assume just wasn’t successful in the objective of the surgery.

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He’s clearly quite a capable chap, too.

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Going percutaneously could be lower risk for your husband if the transarterial route is tortuous (e.g. very twisted) it is always possible for the guide wire for the catheter to snag the artery and cause a bleed. It may be that sort of thing that is putting Dr Rennie off the arterial route.

The one question I’ve got in my mind is when they go in via the femoral artery or the radial artery, there’s a whole bunch of pressing down on the wound afterwards while it all heals up a bit. How do you do that with an intracranial insertion? This feels like the risk area for me but there’s bound to be an explanation.

I hope it is useful for me to ask these kinds of questions; I don’t know any more about this stuff than you do.

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Hello,
The article I referenced is one that I found as a possible explanation. Hopefully it is as you say it is. He did identify the exact pulsing point at the top of the skull and seemed happy with that.

Unsuccessful procedure because the previous case was more complex than my husbands it seems.

Appreciate your input, thank you.

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That is a great question and will ask the nurse when she calls to fix a date.

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Absolutely important for me.

I was also wondering why they are not considering Gamma Knife Radio surgery? Any thoughts?

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If your husband’s AVM is in the same place as the article, it’s a DAVF – i.e. in what I think are fairly high flow vessels in the dura mater. In this regard, I think embolization and/or surgery tend to be preferred. For some reason embolization seems to be more popular with DAVFs. It’s very much on the surface and possibly quite big vessels. I don’t know v much about gamma but I get the impression it is good for smaller vessels and/or a nidus (mass of vessels) and it is also often used to get to places where open surgery would do too much damage getting to the site. By contrast, you can’t thread a catheter through the really tiny vessels.

So I’m sure embolization then craniotomy are the preferred approaches because it is big enough to do this way and very much on the surface, so easy to get to. It may be, if there is a decent amount of blood shunting through that they want to address it sooner rather than later: gamma knife also takes a long time to work and you do have the risk of a bleed meanwhile.

That you’re in the UK means there is also a focus on cost and a craniotomy I’m sure must be more expensive (he’ll need more care) than an embolization.

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