A case of a paraspinal arteriovenous fistula presenting with retroperitoneal hemorrhage treated by staged transarterial and transvenous embolization

We report a rare case of a paraspinal arteriovenous fistula (AVF) treated by combined transarterial and transvenous embolization (TAE/TVE) A 72-year-old woman was admitted after a traffic accident. Abdominal enhanced CT disclosed pre-existing large varices at the L3-L4 level in the right retropentoneum with multiple feeding arteries and veins draining into the extradural venous plexus in the spinal canal. The lesion was diagnosed as a paraspinal AVF. Four days later, the patient went into a state of shock. Emergency abdominal CT showed retroperitoneal hemorrhage due to rupture of the varix. TAE of the feeders from the right L1-L4 arteries was performed, and rebleeding from the varix was prevented. Three months later, follow-up CTA showed regrowth of the AVF, and TVE was performed. Two microcatheters were navigated transveriously into the varix, and detachable coils were delivered into the small compartment just downstream to the shunts, leading to complete obliteration. We conclude that transarterial flow reduction followed by occlusion of the venous side of the shunts is effective to achieve cure of a complex and high-flow paraspinal AVF.