Neurosurgical versus endovascular treatment of craniocervical junction arteriovenous fistulas: a multicenter cohort study of 97 patients

Abstract

OBJECTIVE Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) are treated using neurosurgical or endovascular options; however, there is still no consensus on the safest and most effective treatment. The present study compared the treatment results of neurosurgical and endovascular procedures for CCJ AVFs, specifically regarding retreatment, complications, and outcomes. METHODS This was a multicenter cohort study authorized by the Neurospinal Society of Japan. Data on consecutive patients with CCJ AVFs who underwent neurosurgical or endovascular treatment between 2009 and 2019 at 29 centers were analyzed. The primary endpoint was the retreatment rate by procedure. Secondary endpoints were the overall complication rate, the ischemic complication rate, the mortality rate, posttreatment changes in the neurological status, independent risk factors for retreatment, and poor outcomes. RESULTS Ninety-seven patients underwent neurosurgical (78 patients) or endovascular (19 patients) treatment. Retreatment rates were 2.6% (2/78 patients) in the neurosurgery group and 63% (12/19 patients) in the endovascular group (p < 0.001). Overall complication rates were 22% and 42% in the neurosurgery and endovascular groups, respectively (p = 0.084). Ischemic complication rates were 7.7% and 26% in the neurosurgery and endovascular groups, respectively (p = 0.037). Ischemic complications included 8 spinal infarctions, 2 brainstem infarctions, and 1 cerebellar infarction, which resulted in permanent neurological deficits. Mortality rates were 2.6% and 0% in the neurosurgery and endovascular groups, respectively (p > 0.99). Two patients died of systemic complications. The percentages of patients with improved modified Rankin Scale (mRS) scores were 60% and 37% in the neurosurgery and endovascular groups, respectively, with a median follow-up of 23 months (p = 0.043). Multivariate analysis identified endovascular treatment as an independent risk factor associated with retreatment (OR 54, 95% CI 9.9–300; p < 0.001). Independent risk factors associated with poor outcomes (a postoperative mRS score of 3 or greater) were a pretreatment mRS score of 3 or greater (OR 13, 95% CI 2.7–62; p = 0.001) and complications (OR 5.8; 95% CI 1.3–26; p = 0.020). CONCLUSIONS Neurosurgical treatment was more effective and safer than endovascular treatment for patients with CCJ AVFs because of lower retreatment and ischemic complication rates and better outcomes.

Spinal Vascular Shunts: Single-Center Series and Review of the Literature of Their Classification

“…In a recent multicenter study in patients with CCJ AVFs, embolization was found to be the main risk factor for ischemic complications [ 64 ]. In this cohort, surgical and endovascular approaches were compared, and the results showed a clear advantage for surgical treatment, both in the success rate and in the number of complications [ 65 ]. Similarly, when the endovascular treatments of dural AVFs of the foramen magnum (FM AFVs) and CCJ AVFs were compared, the latter had a lower rate of occlusion and more ischemic complications [ 66 , 67 ].…”

Arteriovenous fistulas in the craniocervical junction region: With vs. without spinal arterial feeders

“…According to the experience of previous studies, microsurgery and interventional embolization were optional treatment strategies for CCJ AVFs. Nevertheless, like AVFs in other parts of the spinal cord, microsurgery was favored for CCJ AVFs, and it usually resulted in better outcomes (5,11,(16)(17)(18)(19). According to the treatment experience of our center, the angioarchitecture of CCJ AVFs was the key to our choice of treatment strategies.…”

“…In a recent multicenter study, the complications' overall incidence was 26% (25/97). Ischemic complications were the most common complications, and the associated risk factors were interventional embolization (OR: 4.3, 95%CI: 1.1-16, p = 0.030) and spinal arterial feeders (OR: 3.8, 95%CI: 1.03-14, p = 0.045) (19,22). In treating CCJ AVFs with complex angioarchitecture, it was necessary to carefully identify the blood vessels to avoid ischemic events, especially during interventional embolization.…”

Efficacy of intraarterial indocyanine green videoangiography in surgery for arteriovenous fistula at the craniocervical junction in a hybrid operating room: illustrative cases

“…Recently, neurosurgery has been reported to result in better treatment outcomes than endovascular treatment. 1 A sufficient understanding of the angioarchitecture and accurate diagnosis of CCJ AVF is crucial for safe and complete surgical elimination but is often difficult due to the complex angioarchitecture of this lesion despite recent advances in angiography.…”