We report stentless reconstructive embolization of a high-flow vertebrovertebral arteriovenous fistula using a double-balloon jailing technique with microsnare-guided retrograde exchange. A 70-year-old woman had pulsatile tinnitus and a cervical bruit. Angiography demonstrated a V3-to-suboccipital cavernous sinus fistula with a single short tract, draining into vertebral venous plexuses and via the posterior condylar vein to the sigmoid sinus, without cortical reflux. Targeted embolization was planned by jailing an embolization microcatheter within the tract using arterial and venous balloon microcatheters. Direct transvenous navigation was prevented by septations and high shunt flow; therefore, an arterial microcatheter was advanced antegrade into the internal jugular vein, where it was captured with a microsnare introduced from the venous side, then drawn back as a coupled system to secure venous access. Subsequent inflation of both balloon microcatheters immobilized the embolization microcatheter and enabled dense coil packing. Angiography confirmed complete obliteration which persisted after balloon deflation. Tinnitus resolved immediately, and imaging showed durable occlusion with no recurrence at 5 years. This approach enables reconstructive obliteration of selected high-flow vertebrovertebral arteriovenous fistulas (VVAVFs) without stent implantation, potentially reducing antiplatelet exposure while preserving bailout options. Microsnare-guided retrograde exchange facilitates device delivery in cases of challenging transvenous navigation.
Suzuki et al. (Wed,) studied this question.