I. Dural arteriovenous fistula (DAVF)

The patient was a 60-year-old female with complex DAVF, left sinus and sinus confluence area involved, multiple arterial blood supply and complex venous drainage, residual shunt after previous transvenous embolization. The treatment team adopted a multimodal strategy, transvenous balloon-assisted embolization combined with arterial superselective embolization, assisted by double balloon technology to control backflow.

Experts discussed that it is necessary to weigh the impact of embolism on cerebellar venous drainage during surgery to avoid the risk of non-target embolism of brainstem perforators; long-term anticoagulation and strict blood pressure management are required after surgery to prevent thrombosis while avoiding blood pressure fluctuations that cause bleeding. At the same time, experts analyzed the trend of embolization material selection, emphasizing the treatment of complications of staged embolization, venous sinus protection technology and device-drug combination.

II. Aneurysm

The patient was a 40-year-old male with hypertension. A 13 mm aneurysm was found in the right ICA. The anterior choroidal artery originated from the aneurysm base and was receiving dual antiplatelet therapy. The treatment used bilateral femoral artery access, navigation of the microcatheter through the anterior communicating artery, and temporary occlusion of the A1 segment of the anterior cerebral artery with a balloon. Coils were placed and stents were implanted to increase the support density at the neck of the aneurysm while avoiding covering the anterior choroidal artery.

During the expert discussion, there was controversy over whether to include the A1 segment in the treatment. The balloon occlusion position, the order of stent and coil placement, and the selection and use of devices such as stent size and coil specifications were also discussed. The thrombosis and vascular occlusion risks and the impact on the anterior choroidal artery when using FD were also focused on.

III. Middle cerebral artery M1 segment stenosis with internal carotid artery tonsillar loop

The patient had symptomatic middle cerebral artery (MCA) stenosis and tonsillar loops on the ipsilateral internal carotid artery (ICA). The treatment team first tried to navigate along the loop with a balloon, and then used the balloon for percutaneous transluminal angioplasty (PTA), slowly inflating during the operation and completely deflated after 1 minute. Then the stent was inserted, and the catheter operation was adjusted according to the vascular anatomy to avoid damaging the blood vessels. The MCA and ICA were examined after the operation.

Experts discussed the key points of balloon navigation and operation, emphasizing the importance of slow inflation to reduce the stretching of vascular fibrosis tissue and improve treatment stability. At the same time, they analyzed the use value of drug-eluting balloons and the potential benefit verification requirements, as well as the use and limitations of coronary stents in various regions.

IV. Treatment of superior cerebellar artery aneurysms with stenting

The patient had unruptured right MCA and left superior cerebellar artery (SCA) aneurysms. The right MCA aneurysm had been clipped, and the left SCA aneurysm was treated this time. Bilateral femoral artery access was used, and the microcatheter was first tried to be navigated to the appropriate position with the assistance of a balloon, and then a stent was placed to allow the SCA to be supplied by the posterior cerebral artery, thereby isolating the aneurysm from the blood flow.

Experts discussed the advantages and disadvantages of various options such as simple coil embolization, stent-assisted coil embolization, and FD treatment in view of the anatomical characteristics of SCA aneurysms, and paid attention to the selection of appropriate length stents to reduce the risk of shortening during placement, as well as how to avoid complications such as damage to blood vessels and thrombosis during the operation.