Dual Balloon-assisted Transarterial Embolization of a Cervical Spinal Epidural Arteriovenous Fistula with Intradural Venous Reflux Arising from the Vertebral Artery

Cervical spinal epidural arteriovenous fistulas with intradural venous reflux are exceptionally rare, and endovascular treatment is particularly challenging when the arterial feeder arises directly from the vertebral artery. We report a 69-year-old man with progressive myelopathy caused by a cervical type A spinal epidural arteriovenous fistula with a feeder arising directly from the left vertebral artery at C6, treated by dual balloon-assisted transarterial n-butyl cyanoacrylate embolization. A balloon guiding catheter was used for proximal vertebral artery flow arrest, whereas an occlusion balloon catheter was positioned across the feeder origin for distal protection and flow-directed microcatheter stabilization. After confirming complete segmental flow arrest, 0.15 mL of 25% n-butyl cyanoacrylate mixed with Lipiodol was injected. Complete angiographic obliteration was achieved without complications, and neurological function gradually improved with marked resolution of spinal cord edema on follow-up magnetic resonance imaging at 3 months. Reported series of transarterial embolization for these fistulas show high obliteration rates but carry a risk of reflux into the parent artery when the feeder arises from a major vessel. In this anatomically rare lesion, the dual balloon configuration provided simultaneous proximal flow arrest, distal protection across the feeder origin, and stabilization of the feeder microcatheter, allowing controlled n-butyl cyanoacrylate injection without proximal reflux. This technique may be a useful endovascular option for selected cases of cervical spinal epidural arteriovenous fistula with direct vertebral artery feeders, although its broader efficacy requires confirmation in larger series.