Endovascular treatment of multiple dural arteriovenous fistulas using gadolinium-based contrast agents in a patient with severe renal dysfunction: a technical report

Background In patients with severe renal failure, the utilisation of iodinated contrast agents during endovascular procedures carries a significant risk of contrast-induced nephropathy. Although there are limited reports on endovascular procedures utilising gadolinium-based contrast agents (GBCAs), reports on their use in the treatment of dural arteriovenous fistulas (DAVFs) are extremely limited, primarily due to the necessity for precise vascular assessment and the typically substantial volume of contrast needed for treatment. Here, we present a case detailing the successful endovascular treatment of a DAVF using a GBCA in a patient with severe chronic kidney disease (CKD), resulting in a favourable outcome. Methods Transarterial embolisation using gadobutrol, a macrocyclic Group II GBCA was performed for multiple DAVFs to prevent further deterioration of renal function with iodinated contrast agents. To minimise the volume of the GBCA, detailed preprocedural assessment was performed using three-dimensional image reconstruction of non-contrast-enhanced 3 T magnetic resonance angiography (MRA) and venography (MRV). Additionally, saline flush-assisted low-volume contrast injections were used during intraoperative angiography. Results The fistulas were treated sequentially, leading to complete closure of all fistulas without contrast-related complications. Renal function remained stable, and follow-up imaging showed no recurrence. Conclusions Preprocedural image reconstruction utilising non-contrast-enhanced MRA/MRV and saline flush–assisted intraoperative contrast injection methods using a GBCA allowed effective embolization without deterioration of renal function. This contrast-sparing technique may be useful when iodinated contrast agents are contraindicated.