Jia Jiang, Siming Gui, Youxiang Li
Paravertebral epidural arteriovenous fistulas (EDAVFs) supplied by small radiculomeningeal or muscular branches can pose significant challenges for endovascular treatment when superselective catheterization is not feasible1,2,3. We present a patient with persistent left-sided neck and shoulder pain and an EDAVF adjacent to the left V3 segment. The fistula was presumed to be supplied by multiple minute muscular or radiculomeningeal branches and drained into the suboccipital venous plexus without cortical or perimedullary venous reflux4. Given the persistent left-sided neck and shoulder pain and relatively high-flow shunting on angiography, together with her concern arising from a prior AVM hemorrhage, the patient elected endovascular treatment after informed discussion. A Synchro-10 microwire could enter a minute feeder, but the Marathon microcatheter could not reach the fistulous point. After right vertebral angiography confirmed adequate collateral supply, a 4.0 × 15mm HyperGlide balloon was positioned in the left V3 segment across the feeder origins. Four 10-minute inflations were performed, separated by 3-minute reperfusion intervals, for a cumulative occlusion time of 40 minutes under continuous neurophysiological monitoring. Immediate postprocedural DSA showed marked flow reduction with a small residual fistula; no embolic agent was used. The patient had no new neurologic deficit and the neck and shoulder pain improved. Complete occlusion was confirmed on 18-month follow-up DSA. Previous studies suggested that alterations in shunt hemodynamics may promote thrombosis and subsequent fistula closure5. Intermittent balloon occlusion may be considered as a highly selected bailout maneuver when superselective access is not feasible, but not as a routine alternative to embolization. Careful preprocedural assessment of collateral circulation and comprehensive intraoperative neurophysiologic monitoring are essential for procedural safety. VIDEO.