Transvenous retrograde pressure cooker technique for embolization of an ethmoidal dural arteriovenous fistula

Ethmoidal dural arteriovenous fistulas (DAVFs) are rare lesions, accounting for approximately 10% of intracranial DAVFs.(1 2) As ethmoidal DAVFs commonly demonstrate cortical venous drainage, treatment is always warranted.(2-6) Endovascular transvenous embolization has been increasingly reported as an effective and safe treatment for ethmoidal DAVFs, and since occlusion of the central retinal artery and resulting blindness are not a concern, it has an advantage over transarterial embolization.(3-6) To ensure curative embolization, we adopted the transvenous retrograde pressure cooker technique (RPCT), creating a plug with n-butyl cyanoacrylate (NBCA) in the draining vein to allow a more comprehensive and efficient injection of Onyx (Medtronic, MN) while avoiding excessive reflux.(7 8) In this technical video (video 1), we report the first case using the transvenous RPCT for successful Onyx embolization of an ethmoidal DAVF, with emphasis on the technical nuances of the RPCT and important tips to avoid periprocedural complications.