Transvenous Embolization for Complex Anterior Cranial Fossa Dural Arteriovenous Fistula Following Prior Embolization: A Case Report.

OBJECTIVE: Anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs) are high-risk lesions because of cortical venous drainage and are generally treated by surgical interruption of the draining vein or transarterial embolization (TAE). Transvenous embolization (TVE) has recently emerged as an alternative treatment in selected cases. CASE PRESENTATION: A 67-year-old man with a residual ACF DAVF after previous bilateral ophthalmic artery Onyx (Medtronic, Irvine, CA, USA) embolization was referred for additional treatment. Repeat TAE was considered anatomically difficult because of distal ophthalmic artery occlusion after prior treatment. Craniotomy was presented as the standard treatment but was declined by the patient. Preoperative imaging demonstrated focal shunt localization and feasible venous access to the foot of the draining vein. TVE was therefore performed using selective venous catheterization and Onyx embolization. Complete angiographic obliteration was achieved without neurological deficit, hemorrhagic complication, or postoperative olfactory disturbance. Because of strong resistance during catheter retrieval, the microcatheter was intentionally retained to avoid venous injury. CONCLUSION: TVE may represent a feasible alternative for selected residual ACF DAVFs after prior embolization when additional arterial access is limited and the venous anatomy is favorable. Careful patient selection and meticulous procedural planning remain essential.