Endovascular therapy of low- and intermediate-grade intracranial lateral dural arteriovenous fistulas: a detailed analysis of primary success rates, complication rates, and long-term follow-up of different technical approaches

Abstract

IntracranIal dural arteriovenous fistulas (DAVFs) are pathological shunts between dural arteries and dural venous sinuses, meningeal veins, or cortical veins. DAVFs account for 10%-15% of intracranial arteriovenous malformations.9 The venous drainage pattern of a DAVF determines its severity and classification according to Borden et al. 1 and Cognard et al. 3 Both of these systems associate cortical venous drainage with increased risk of intracranial hemorrhage and neurological deficits. 2,4,6,7,13,15,16 During the past 2 decades, embolization has become the first-line treatment for DAVFs. In particular, the invention of highly compliant, inflatable occlusion balloons and the Onyx liquid embolic agent (ev3 Neurovascular) opened a new horizon in the endovascular treatment of DAVFs. By temporarily inflating a large-lumen compliant balloon in the diseased sinus compartment during the injection of Onyx into an arterial feeder, this combined sinus-preserving embolization (CSPE) approach is supposed to preserve the natural venous drainage pattern and allow a better penetration of the fistula network by the liquid embolic agent.Transvenous embolization (TVE) is performed by retrograde catheterization of the involved dural sinus or cortical vein, followed by deposition of coils and/or liquid abbreviations CCA = common carotid artery; CCF = carotid cavernous fistula; CSOE = combined sinus-occluding embolization; CSPE = combined sinus-preserving embolization; DAVF = dural arteriovenous fistula; DSA = digital subtraction angiography; ECA = external carotid artery; SO = sinus-occluding; SP = sinus-preserving; TAE = transarterial embolization; TVE = transvenous embolization. methods Clinical symptoms, complication rates, and Cognard grading prior to and after endovascular DAVF treatment using different technical approaches was retrospectively analyzed in 36 patients with lateral DAVF Cognard Types I-IIb. The long-term success rate was determined by a standardized questionnaire. results The SO approaches offered a higher rate of definitive fistula occlusion (93% SO vs 71% SP) but were accompanied by a significantly higher complication rate (33% or 20% SO vs 0% SP). The patients interviewed reported very high satisfaction with their health in long-term follow-up in both groups. conclusions A higher rate of definitive fistula occlusion in the SO group was attained at the price of a significantly higher complication rate. The SP approaches offered a good primary success rate in combination with a very low complication rate. Despite some limitations of the data (e.g., a small sample size) the authors thus recommend an SP variant as the primary therapeutic option for the endovascular treatment of low-and intermediate-grade DAVFs. The SO approaches should be restricted to cases in which SP treatment does not achieve a downgrading to no worse than Cognard Type IIa.http://thejns.org/doi/abs/10.3171/2016.2.JNS152081

Updates in the management of cranial dural arteriovenous fistula

“…Major complications of a transvenous approach include vessel perforation (particularly during navigation of the wire or catheter), cerebral haemorrhage and venous infarction 33 40 46 51. Cranial nerve injury can occur during navigation or secondary to thrombosis or overpacking and involved venous region 52.…”

“…Visual loss, glaucoma and acute exophthalmos were reported following transvenous approach via superior orbital vein for treatment of indirect CCF 53 54. Following transvenous embolisation of dAVF, venous drainage of normal brain could alter and lead to intracranial hypertension that can present with worsening of headache, confusion and neurological deficit 51. Mediastinal perforation, cardiac embolism and pulmonary embolism are the other potential complications of transvenous approach 46 51.…”

“…Following transvenous embolisation of dAVF, venous drainage of normal brain could alter and lead to intracranial hypertension that can present with worsening of headache, confusion and neurological deficit 51. Mediastinal perforation, cardiac embolism and pulmonary embolism are the other potential complications of transvenous approach 46 51. If the fistula has pial arterial supply, in addition to dural arterial supply, sole reliance on a transvenous approach without retrograde penetration of pial feeders can result in haemorrhage.…”

Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus

“…The advantages of transvenous balloon protection during simultaneous transarterial embolization include the prevention of inadvertent occlusion of the lumen of a functioning sinus required for cerebral venous drainage and propagation of embolic material into adjacent cortical or deep cerebral veins. Ertl et al 13 recently conducted a retrospective comparison of sinus-preserving and sinus-occluding endovascular treatment techniques for low-and intermediate-grade dAVFs involving the transverse and sigmoid sinuses (Cognard type I-IIb). A higher rate of permanent fistula occlusion was achievable with sinus-occluding techniques than with the sinus-preserving technique (93% versus 71%), but this came at the cost of a higher complication rate (33% versus 0%).…”

“…Techniques aiming to preserve the underlying sinus may have lower complication rates than sinus-occluding embolization techniques, in which the recipient venous sinus has to be sacrificed. 13 Therefore, transarterial balloon-assisted embolization with a concomitant transvenous balloon protection technique theoretically has the advantages of both techniques combined; this combination leads to increased occlusion and reduced complication rates. The purpose of this study was to report the angiographic and clinical outcomes of patients with dAVFs of the transverse and sigmoid sinuses treated with a combined approach of transarterial balloon-assisted endovascular embolization and double-lumen balloon microcatheters with concomitant transvenous balloon protection.…”