J Cerebrovasc Endovasc Neurosurg.  2023 Sep;25(3):253-259. 10.7461/jcen.2023.E2022.10.002.

Image fusion technique using flat panel detector rotational angiography for transvenous embolization of intracranial dural arteriovenous fistula

• Choi JH
• Shin YS
• Kim Bs

• KMID: 2546161
• DOI: http://doi.org/10.7461/jcen.2023.E2022.10.002

Abstract

Precise evaluation of the feeders, fistulous points, and draining veins plays a key role for successful embolization of intracranial dural arteriovenous fistulas (DAVF). Digital subtraction angiography (DSA) is a gold standard diagnostic tool to assess the exact angioarchitecture of DAVFs. With the advent of new image postprocessing techniques, we lately have been able to apply image fusion techniques with two different image sets obtained with flat panel detector rotational angiography. This new technique can provide additional and better pretherapeutic information of DAVFs over the conventional 2D and 3D angiographies. In addition, it can be used during the endovascular treatment to help the accurate and precise navigation of the microcatheter and microguidwire inside the vessels and identify the proper location of microcatheter in the targeted shunting pouch. In this study, we briefly review the process of an image fusion technique and introduce our clinical application for treating DAVFs, especially focused on the transvenous embolization.

Keyword

Dural arteriovenous fistula; Transvenous approach; Image fusion; Flat panel detector rotational angiography

Figure

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  Fig. 1. Algorithm to make various fusion images. VR, volume rendering; MPR, multiplanar reconstruction

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  Fig. 2. Example of various fusion images. (A) Single vessel volume rendering (VR) fusion image with mask of vessel 1 and sub of vessel 1. (B) Single vessel multiplanar reconstruction (MPR) axial fusion image with mask of vessel 1 and sub of vessel 1. (C) Dual vessel VR fusion image with sub of vessel 1 and sub of vessel 2. (D) Dual vessel MPR fusion image with nat fill of vessel 1 and nat fill of vessel 2.

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  Fig. 3. Illustrative case of 44-year-old woman with conjunctival injection and periorbital swelling of her right eye. (A) Initial DSA showed dural arteriovenous fistula (DAVF) involving right cavernous sinus (CS) with the cortical venous reflux (CVR) and the occluded inferior petrosal sinus (IPS, yellow circle). (B) By use of pretherapeutic various fusion images, the fistulous point was exactly identified. Even though there were numerous feeders arising from right external carotid artery (ECA, yellow arrow), right internal carotid artery (ICA, red arrow), and left ICA (white arrow), the almost all feeders converged on the superomedial portion of the CS. (C) First intraprocedural fusion image with DRcare and initial DSA24 showed that the microcatheter tip entered the groove for IPS (white arrow). Second fusion image obtained after more advancing the microcatheter demonstrated the wrong direction of the microcatheter tip (yellow arrow). Third fusion image showed that the microguidwire was placed just below the entry point of the occluded CS (red arrow). The microcatheter was finally delivered into the target reflux vein through the CS and this was verified by 4th fusion image. (D) We put the coils from cortical vein to the target fistulous point (red circle) located in superomedial portion of the CS in order and could eventually achieve complete obliteration. DSA, Digital subtraction angiography

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