A Left Transradial Approach with the Upper Limb in External Rotation for Embolization of Sacral Vascular Lesions: A Technical Note

Objective: Spinal arteriovenous shunt diseases in the sacral region are exceedingly rare and present unique challenges for endovascular access, particularly in patients with tortuous aortoiliac anatomy. While the transradial approach (TRA) is emerging as a less invasive alternative to transfemoral access, the left TRA with external upper-limb rotation may offer additional advantages for targeting sacral lesions. Case Presentation: We report a case of a 51-year-old woman presenting with progressive lower back pain, bilateral lower extremity weakness, and gait disturbance. Images revealed a perimedullary arteriovenous fistula (AVF) at the thoracolumbar level and an extradural AVF at the sacral region. After surgical treatment of the thoracolumbar lesion, the sacral extradural AVF was embolized using a left distal TRA, with the patient's left upper limb externally rotated by approximately 90°. A 6-Fr, 122-cm guiding sheath was advanced from the anatomical snuffbox into the right internal iliac artery, and the fistula was then accessed via the right lateral sacral artery using a microcatheter, followed by coil and liquid embolic agent deployment for complete occlusion. Conclusion: The left TRA with external upper limb rotation represents a feasible, safe, and potentially advantageous technique for endovascular treatment of sacral vascular lesions, particularly in patients for whom transfemoral or right TRA are unsuitable.