Stepwise Incisionless Percutaneous Flow-Control Treatment of a High-Flow Scalp Arteriovenous Fistula with a Large Superficial Venous Pouch: A Case Report.

OBJECTIVE: Scalp arteriovenous fistulas (AVFs) with multiple tortuous superficial feeders and a large venous pouch can require meticulous flow control during treatment. Open surgical excision may be associated with blood loss, wound-healing problems, and cosmetic concerns, whereas percutaneous liquid embolization of a high-flow superficial shunt carries a risk of nontarget migration and scalp necrosis. We report an incisionless, stepwise percutaneous flow-control strategy for such a lesion. CASE PRESENTATION: A man in his 50s presented with a progressively enlarging, pulsatile right temporal mass, pulsatile tinnitus, and visual fatigue 30 years after head trauma. DSA revealed a high-flow scalp AVF supplied by the right superficial temporal artery (STA), the right occipital artery, and the contralateral STA, draining through a 2.5-cm superficial venous pouch; the lesion corresponded to Cho-Do type II and Yakes type IIb. We performed a stepwise percutaneous intervention. First, we injected epinephrine-containing lidocaine around the pouch to constrict distal feeding arteries. Second, we punctured the primary draining vein and deployed microcoils to establish a mechanical scaffold. Third, under circumferential compression, we sequentially injected 25% and 30% n-butyl cyanoacrylate-Lipiodol (Guerbet, Villepinte, France) mixtures via direct puncture to obliterate the posterior and anterior compartments. Finally, we occluded the residual STA feeder using ultrasound-guided percutaneous suture ligation. The patient experienced no ischemic cutaneous complications. DSA at 12 months confirmed complete AVF obliteration. CONCLUSION: In selected superficial scalp AVFs, combining pharmacological inflow reduction, direct-puncture coil scaffolding, circumferential compression, and ultrasound-guided percutaneous suture ligation may provide a less invasive alternative to open resection.