Glue embolization with guide catheter dextrose push of a recurrent dural arteriovenous fistula previously embolized with Onyx: neuroendovascular surgical video.

Onyx (ethylene vinyl alcohol, ev3, Irvine, California) is commonly used to treat dural arteriovenous fistulas (DAVF) and presents several advantages over n-butyl cyanoacrylate glue (Codman Neurovascular Inc, Raynham, Massachusetts), including slower more controlled injections and better penetration via radial casting. However, Onyx is non-thrombogenic and may result in incomplete casting, recanalization, and DAVF recurrence. Here, we demonstrate glue embolization with guide catheter dextrose push of a recurrent DAVF previously embolized with Onyx. A 79-year-old female diagnosed with a Cognard IIA+B DAVF was successfully treated with transarterial Onyx injection. 6-month follow-up angiogram, however, revealed recurrence of the DAVF with recanalization of the previously embolized draining vein. She subsequently underwent retreatment using glue embolization with guide catheter dextrose push. Informed written consent was obtained. A Magic microcatheter (Balt Extrusion, Irvine, California) was passed via a 6-French Envoy guide catheter (Codman Neurovascular, Raynham, Massachusetts) in the external carotid artery and was used to select the superficial temporal artery and then navigated distally through a trans-osseous connection into the dura. A dilute 12.5% concentration of glue was injected slowly and continuously and was seen to fill in spaces within the old Onyx material. Dextrose 5% in water was concomitantly injected through the guide catheter to ensure distal migration of the glue and occlusion of the draining vein. Glue embolization with dextrose push is a valuable treatment option for DAVF, especially in smaller recurrent feeders that can fill in the Onyx recanalized cast. The 6-months follow up angiogram showed persistent occlusion of the dural fistula.