Combined transarterial and transvenous embolization of multi-hole pial arteriovenous fistula with large varix

Background: Pial arteriovenous fistula (AVF) is a vascular fistulous disease in which the cerebral pial artery and vein are directly connected without the intervening nidus within a sub-pial space. Multi-hole pial AVFs, wherein multiple feeders flow into one drainer, are usually formed with complex angioarchitecture and are difficult to treat. Methods: A rare case of an adult patient with hereditary hemorrhagic telangiectasia and multi-hole pial AVF was described. A 23-year-old woman was referred to our hospital. She was previously diagnosed with left cerebellar pial AVF with multiple feeders (bilateral superior cerebellar artery and common trunk of the left anterior inferior cerebellar artery and posterior inferior cerebellar) and large varix that had been untreated for 9 years. The enlargement of the large varix with the new second varix formation was revealed by angiography. Although asymptomatic, considered to be a risk for future hemorrhage was the continuous high hemodynamic stress. Results: Endovascular embolization was performed by securing safe transarterial n-butyl-2-cyanoacrylate injection by transarterial and transvenous coil placement to the shunt points and feeders, resulting in total occlusion of the fistula without any complications. Extensive transvenous coil placement inside the varix allowed safe embolization of the entire fistula with multiple high-flow feeders. Moreover, bidirectional (transarterial and transvenous) retrograde coil embolization enabled firm obliteration of the shunt points. Conclusions: Performing combined transarterial and transvenous embolization in a well-balanced manner was considered to treat multi-hole pial AVF to provide a safe and effective embolization.