Long-term angiographic results of endovascularly “cured” intracranial dural arteriovenous fistulas

Abstract

Dural arteriovenous fistulas (DAVFs) are abnormal communications between dural arteries and dural venous sinuses or subarachnoid veins and account for approximately 10%-15% of all intracranial vascular malformations. 11Treatment of these lesions is based on the presenting symptoms and the presence of cortical venous reflux. The goal of treatment is surgical or endovascular occlusion of the fistula or fistulous nidus or at least the disconnection of the feeding vessels and the draining veins. Embolization of DAVFs can be achieved using a variety of embolic agents. Onyx (ethylene vinyl alcohol, ev3) was FDA approved in 2005 for preoperative embolization of cerebral arteriovenous malformations (AVMs), and has since been successfully used to treat other vascular lesions such as spinal AVMs and cerebral DAVFs as well as various tumors.8 Although, endovascular "cure" of cerebral DAVFs using Onyx has been reported by multiple centers, the incidence of recurrence following initial angiographic obliteration has not been well established. 1,7,9,12 In this article, we present a series of patients with cerebral DAVFs who underwent endovascular embolization with a curative intent. Our aim was to study the incidence and the factors affecting recurrence. obJective Dural arteriovenous fistulas (DAVFs) are complex lesions consisting of abnormal connections between meningeal arteries and dural venous sinuses and/or cerebral veins. The goal of treatment is surgical or endovascular occlusion of the fistula or fistulous nidus or at least the disconnection of the feeding vessels and the draining veins. Delayed angiographic data on previously embolized dural fistulas is lacking. The authors report their experience and the long-term angiographic results with embolization of intracranial DAVF using Onyx. methods All cases of DAVF treated primarily with Onyx at the authors' institution from 2006 to 2013 were retrospectively reviewed. Patient demographics, fistula characteristics, embolization details, and angiographic follow-up were analyzed. results Fifty-eight patients with DAVFs were treated during the study period. Twenty-two patients were treated with open surgery with or without prior embolization. Thirty-six patients were treated with embolization alone, of whom 26 underwent an attempt at curative embolization and are the subject of this review. All but 2 of these patients were treated in a single session. Angiographic "cure" was achieved in all cases following treatment. Follow-up angiography was performed in 21 patients at a mean of 14 months after treatment (range 2-39 months). Asymptomatic angiographic recurrence of the fistula was evident in 3 of the 21 patients (14.3%). On reviewing the procedural angiograms of the cases in which the DAVFs recurred, it was observed that the Onyx cast did not reach the venous portion in 1 case, whereas it did reach the vein in the other 2 cases. coNclusioNs Recurrence following initial angiographic cure of DAVF is not uncommon. Incomplete penetration of the embolic material into the proximal ...

Evolution of treatment and a detailed analysis of occlusion, recurrence, and clinical outcomes in an endovascular library of 260 dural arteriovenous fistulas

“…2,[25][26][27][28] We chose the term "initial angiographic occlusion" rather than "cure" to refer to dAVFs occluded after initial treatment. We reserve the term "cure" to refer specifically to dAVFs with radiographic evidence of persistent vein/fistula casting and persistent angiographic occlusion at least 4 months after treatment on formal complete angiographic evaluation.…”

Transarterial Onyx Embolization of Intracranial Dural Fistulas: A Prospective Cohort, Systematic Review, and Meta-Analysis

“…Onyx embolic material has been extensively used due to its non-adhesive properties, allowing prolonged injection times with good lesion penetration, and convenient control for the operator (2). Since the introduction of Onyx in 2005, several single-center studies have demonstrated acceptable rates of DAVF occlusion, morbidity, and mortality for patients treated with Onyx via trans-arterial approach (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21).…”

Treatment of Superior Sagittal Sinus Dural Arteriovenous Fistula by Transarterial Multiple Balloon-assisted Onyx Embolization: A Case Report

“…In the second half of the TAE procedure with balloon guiding catheters, blood flow from the bilateral MMAs was controlled by the Optimo balloons placed in the external carotid artery, allowing Onyx to be more readily refluxed into their feeding arteries. Although Onyx is considered to reflux easily into feeding arteries, however, when considering the high recurrence rate reported by Ambekar et al, 11) Onyx should be injected into the shunt and the proximal part of venous drainage, as well as retrogradely into feeding arteries. Our TAE procedure with sufficient flow control contributes in the decreasing the risk of recurrence.…”

“…While a higher occlusion rate was reported with TAE using Onyx compared with TAE using NBCA, there are some potential recurrence issues at long-term follow-up. Ambekar et al 11) reported that 14.3% of the patients exhibited angiographic recurrences at a mean follow-up period of 14 months after receiving prior curative TAE using Onyx and were judged angiographically to have been "cured"; recurrences were also frequently observed within 1 year after treatment. Insufficient penetration of the embolic material to the shunt and venous drainage, and failure to achieve complete occlusion of the venous drainage, were suggested as factors responsible for this recurrence.…”