Endovascular management of spinal dural arteriovenous fistulas

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Spinal dural arteriovenous fistulas (DAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy, yet remain inefficiently diagnosed lesions. Over the last several decades, the treatment of spinal DAVFs has improved tremendously due to improvements in neuroimaging, microsurgical, and endovascular techniques. The aim of this paper was to review the existing literature regarding the clinical characteristics, classification, and endovascular management of spinal DAVFs.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A search of the PubMed database from the National Library of Medicine and reference lists of all relevant articles was conducted to identify all studies pertaining to spinal DAVFs, spinal dural fistulas, and spinal vascular malformations, with particular attention to endovascular management and outcomes.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The ability to definitively treat spinal DAVFs using endovascular embolization has significantly improved over the last several decades. Overall rates of definitive embolization of spinal DAVFs have ranged between 25 and 100%, depending in part on the embolic agent used and the use of variable stiffness microcatheters. The majority of recent studies in which <jats:italic>N</jats:italic>-butyl cyanoacrylate or other liquid embolic agents were used have reported success rates of 70–90%. Surgical treatment remains the definitive option in cases of failed embolization, repeated recanalization, or lesions not amenable to embolization. Clinical outcomes have been comparable to surgical treatment when the fistula and draining vein remain persistently occluded. Improvements in gait and motor function are more likely following successful treatment, whereas micturition symptoms are less likely to improve.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Endovascular embolization is an increasingly effective therapy in the treatment of spinal DAVFs, and can be used as a definitive intervention in the majority of patients that undergo modern endovascular intervention. A multidisciplinary approach to the treatment of these lesions is required, as surgery is required for refractory cases or those not amenable to embolization. Newer embolic agents, such as Onyx, hold significant promise for future therapy, yet long-term follow-up studies are required.</jats:p></jats:sec>

Long-term outcomes after surgical and endovascular treatment of spinal dural arteriovenous fistulae

“…The optimal management of SDAVF by initial surgery or embolization remains controversial and a multidisciplinary approach has been suggested [7,16,[18][19][20]. It involves embolization as the initial management tool and surgery if embolization fails or is considered difficult and/or unsafe.…”

Spinal Dural Arteriovenous Fistulas: Clinical and Radiological outcome of Endovascular Treatment

“…2,32 A trend has suggested that earlier exclusion of the fistula correlates with improved motor function. 30 In general, studies suggest that bladder function, if affected, does not recover. 6,17,32 In our study improvement in motor function after treatment was more likely to occur than improvement in micturition dysfunction.…”

“…33 Endovascular embolization is an effective therapy in the treatment of SDAVFs and can be used as a definitive intervention in most patients. 30 The success of endovascular treatment is believed to be dependent on complete occlusion of the proximal radicular draining vein and the site of the fistula itself. The goal of treatment, regardless of the type of intervention, is to eliminate the abnormal arteriovenous communication to avoid progression or worsening of the neurologic symptoms.…”

“…The goal of treatment, regardless of the type of intervention, is to eliminate the abnormal arteriovenous communication to avoid progression or worsening of the neurologic symptoms. 30 The aim of this study was to evaluate the clinical and radiological outcome of patients with SDAVFs that were primarily treated with endovascular embolization in our institutions, with assessment of feasibility, safety and efficacy of endovascular treatment.…”

Absence of abnormal vessels in the subarachnoid space on conventional magnetic resonance imaging in patients with spinal dural arteriovenous fistulas

“…1,8,25 Currently, surgical ligation, endovascular embolization, and a multidisciplinary approach are all used for the treatment of spinal DAVFs. 9,30,32,33 Once the diagnosis of a spinal DAVF has been made and the fistula has been successfully closed, a majority of patients, up to 80%-90% in some series, 17 will demonstrate either improvement or stabilization of symptoms, particularly lower-extremity strength. 8,13 Aghakhani et al 2 showed that even patients with complete paraplegia at the time of treatment can demonstrate a significant improvement in function following intervention.…”