Onyx embolization for dural arteriovenous fistulas: a multi-institutional study

Abstract

BackgroundAlthough the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance.ObjectiveTo carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs.MethodsFrom the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models.ResultsA total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0–129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes.ConclusionsIn this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.

Is the Middle Meningeal Artery the Optimal Path for Dural Arteriovenous Fistula Embolization?

“…If the fistula ruptures during EVT under the high pressure of Onyx casting or if too many draining veins are occluded, intracranial hemorrhage may occur. Therefore, EVT must be performed carefully and gently to prevent damage to the draining veins (18). If the draining veins are too thick and near the aqueduct of the midbrain, thrombosis in the draining veins after EVT may cause hydrocephalus (19), and a cerebrospinal fluid shunt is needed.…”

Tentorial venous anatomy of mice and humans

“…Given this homology, we believe mice can be used as a model to study the development of this venous system and its anatomic, physiologic, and pathologic relationships. For example, idiopathic vascular pathologies of the tentorium, such as tentorial dural arteriovenous fistulas (DAVFs), have been reported to have worse outcomes than DAVFs in other locations ( 14 ). We believe that these aberrant connections are likely the embryologic remnants of the tentorial venous plexus that give rise to the TTVS.…”

Endovascular embolization of high-grade cerebral dural arteriovenous fistulas - assessment of long-term recurrences

“…2 While most low-grade dAVFs (Cognard < IIB) undergo conservative management, treatment is considered in cases where symptoms are present. 4,5 In high-grade or “malignant” (Cognard ≥ IIB) dAVFs, treatment is indicated to completely obliterate the dAVF and by such, decrease the risk of hemorrhage. 6…”

“…7 The approval of the Onyx (eV3, Irvine, California, USA) embolic material by the Food and Drug Administration for the treatment of cerebral arteriovenous malformations in 2005 was a revolutionary step for EVT of dAVFs due to the practicability at which this ethylene-vinyl alcohol-based (EVOH) copolymer could be deployed, and its ability to deeply penetrate the dAVF nidus. 5,7–10 Despite the technical advances, long-term recurrences following complete angiographic “cure” of the dAVF are still observed. 5,7,8,10–17 In this study, we aim to investigate the rates and timing of recurrence following radiographic obliteration from last treatment in a high-grade dAVF cohort.…”