Endovascular treatment of anterior cranial base dural arteriovenous fistulas as a first-line approach: a multicenter study

OBJECTIVE Anterior cranial fossa dural arteriovenous fistulas (DAVFs) have been almost exclusively considered as surgical lesions. However, new advances in endovascular technology have made the endovascular treatment (EVT) of ethmoidal DAVFs feasible. The aim of this study was to report the clinical and angiographic outcomes of patients harbor-ing DAVFs of the anterior cranial fossa who had undergone EVT as a first-line approach.METHODS This was a retrospective study of a consecutive series of patients harboring anterior cranial base DAVFs who had undergone EVT as a first-line approach at four institutions. Angiographic follow-up was performed at 6 months. Immediate and late serious clinical events were assessed during follow-up, including death and stroke. Special emphasis was given to visual status before and after the treatment.RESULTS Between 2008 and 2020, 37 patients with ethmoidal DAVFs were admitted to the participating centers. In 2 patients, EVT was not attempted; therefore, 35 patients underwent EVT as a first-line procedure. An isolated transarteri- al approach was performed in 19 (54.3%) patients. The transvenous approach was performed exclusively in 12 (34.3%) patients, and combined access was used in 4 (11.4%) patients. The most frequently used arterial access route was the ophthalmic artery in 82.6% of the patients. Immediately, complete angiographic occlusion was achieved in 31 (91.2%) of 34 patients whose treatment was accomplished. Six-month control angiography revealed that 30 (88.2%) DAVFs were totally occluded. Complications occurred in 3 (8.8%) patients, including 1 (2.9%) patient who had central retinal artery occlusion. No significant difference in complications or occlusion rates was noted between the transarterial and transve- nous approaches.CONCLUSIONS Most anterior cranial base DAVFs can be successfully treated via an endovascular approach. Neu-rological and visual complications are rare, even if the ophthalmic artery is used as the primary access route. Efforts should be focused on prospectively comparing the results of EVT and surgical management.

Automated summary

This study retrospectively analyzed the clinical and angiographic outcomes of patients with anterior cranial fossa DAVFs who underwent EVT as a first-line approach. The results showed that most anterior cranial base DAVFs can be successfully treated with an endovascular approach, with rare neurological and visual complications. The primary access route of ophthalmic artery showed good outcomes. Future efforts should focus on comparing EVT and surgical management.