“…However, there is evidence that percutaneous treatment with occlusion reduces the probability of cerebral embolization, and this treatment is indicated in all symptomatic patients (cyanosis, dyspnea and paroxysmal embolism) and in those who present with a fistular sac >3mm in diameter, due to a higher incidence of embolic events. 8 In cases with large caliber fistulas, in which the use of coils is not feasible due to the chance of their embolization and important complications, the use of vascular plugs, associated or not with coils, is the best approach, as also described in the case reports by Erudilho et al 8 and Faria et al 9 The surgical approach is restricted to complex cases, when the supplying arteries have very large calibers, and the vascular anatomy does not favor percutaneous intervention, or cases with unsuccessful embolization and/or that have not achieved satisfactory results. 11 In the three cases, a surgical approach was not necessary after the percutaneous procedure.…”