Preparation for Surgery for Dural Arteriovenous Fistulas in Children

Indications for the Procedure

• Symptoms indicating surgery: A hemorrhagic presentation, cardiac failure and/or presence of cortical venous drainage with venous hypertension.

Preoperative Orders

• Standard preparation for surgery: Blood type and cross, complete set of labs (CBC, BMP, and coagulation studies), as well as adequate intravenous hydration must be achieved prior to treatment.
• Antiepileptic drugs: If seizures are present, use of antiepileptic drug is advised.
• Blood products: Fresh frozen plasma, platelets and concentrated prothrombin complex need to be reserved and readily available in case of major bleeding.

Anesthetic Considerations

• Blood Loss: Blood volume loss can be a major concern. Make sure your anesthesiologist is prepared should major bleeding occur.
• Fluid overload: Fluid overload can also be a concern in patients with cardiac failure. The recommended contrast dose for interventional procedures should be kept to approximately 4 mL/kg.

Devices to be Implanted

• Aneurysm clips: In order to disconnect the fistula, permanent aneurysm clips may be used.
• Meshes: In cases of large bony defects after skeletonization, absorbable and non-absorbable meshes may be used along with bone substitutes.
• Dural substitutes: In cases of a large dural defect after resection, dural substitutes may be used.

Ancillary/Specialized Equipment

• Operative microscope: An operative microscope should be ready before the dura is opened.
• Stereotactic equipped microscope: An stereotactic, computer assisted guidance equipped microscope might be used to acquire additional information regarding the DAVF angioarchitecture, and might help in assessing the fistula disconnection.
• Intraoperative angiogram: An intraoperative digital subtraction angiogram might be used to confirm complete obliteration after surgery. The groin should be prepped and draped before the case is started.
• Intraoperative Doppler: Intraoperative Doppler can also assist with detection of residual flow in the fistula.