Arteriovenous Fistulas (AVFs) Treatment in Children

The goal in treating arteriovenous fistulas (AVFs) is to close off the fistula before the abnormal blood flow can damage the brain or spinal cord. The treatment team at the Cerebrovascular Surgery and Interventions Center customizes the approach to each child, depending on the type of AVF, where it is located and the pattern of surrounding vessels.

For pial AVFs, we almost always recommend treatment as soon as possible. In about half of the children we see, we are able to use a minimally invasive, catheter-based treatment known as endovascular embolization. Dural AVFs are sometimes less urgent, and can almost always be treated with endovascular techniques.

When the AVF cannot be closed with the endovascular approach, we treat it with neurosurgery, or through a combined surgical/endovascular approach. In our experience, most children have an excellent prognosis.

Endovascular embolization

Endovascular embolization uses a catheter (a thin, flexible tube) to inject various glue-like compounds into the vessel or insert tiny devices to close off the fistula.

The procedure is performed under general anesthesia. A guide catheter is inserted into an artery in the child’s groin through a tiny incision and, guided by live x-ray pictures, advanced to the vessels in the neck. The neuro-interventional radiologist then injects a contrast solution (a dye) through the catheter to visualize the blood vessels.

Multiple images may be taken to determine which vessels need embolization. Once these have been identified, a thinner microcatheter is inserted through the first catheter and advanced directly into the vessels in the diseased brain area to inject the embolic agent or device.

Most children have no pain or other symptoms with embolization, and recovery is usually rapid. In some instances, a child will be admitted to the ICU for several days of observation. Patients usually leave the hospital within a few days and return for a follow-up office visit within a few weeks. Follow up may be in part through video teleconference for patients who live outside the Boston area.

Though there are some serious risks, complications from embolization are rare. Because it uses x-rays, the procedure does require exposing patients to ionizing radiation. Because children are more sensitive to radiation than adults, we have established protocols that enable us to deliver the lowest possible dose.

Medical treatment

In addition to treating the AVF itself, children with blood-clotting abnormalities can be treated with medications to reduce their risk for AVF complications. In children who have mutations identified on genetic testing, follow-up with a genetic counselor and other medical specialists may be recommended.