Transuterine Ultrasound-Guided Fetal Embolization of Vein of Galen Malformation, Eliminating Postnatal Pathophysiology

espite decades of technique refinement of transarterial embolization and the establishment of specialty referral centers, fetuses diagnosed with vein of Galen malformation continue to have high mortality, with survivors facing high rates of severe neurological and cognitive morbidity. 1 Low resistance in the vein of Galen malformation arteriovenous shunt induces highflow physiology that compromises cerebral perfusion and induces cardiopulmonary stress. In utero, the placental circulation is also low resistance, providing compensation and fetal protection. Thus, most infants suffer decompensation postnatally rather than in fetal life, with exacerbation upon ductus arteriosus closure. Moreover, neonatal embolization itself carries significant risk of iatrogenic cerebral injury, even at the hands of the most experienced practitioners.