Endovascular treatment of cranial dural arteriovenous fistulae: a single-centre, 14-year experience and the impact of Onyx on local practise

Dural arteriovenous fistulae (DAVFs) are a potentially dangerous group of intracranial arteriovenous shunts with significant morbidity and mortality. Treatment has traditionally included transvenous and/or transarterial embolisation, which may be followed by surgical ligation. This study assesses the impact of Onyx on treatment. Forty-nine consecutive patients referred for endovascular management of DAVFs between 1994 and 2008 were included in a retrospective, intention-to-treat analysis. DAVFs managed conservatively or purely surgically were excluded. Success rates and complications were compared between patients treated by transvenous, transarterial Onyx and transarterial non-Onyx material embolisation. Fifty-six separate DAVFs were detected in 49 patients. Embolisation of 52 DAVFs was performed or attempted. Transvenous sinus occlusion of ten type I or II DAVFs resulted in cure but was unsuccessful in a single type IV fistula and three of the four indirect carotico-cavernous fistulae treated in this way. Two type I and nine type III/IV were identified in the transarterial, non-Onyx group and three of 11 (27.3%) were cured. Amongst the six type II and 20 type III/IV DAVFs belonging to the transarterial Onyx group, cure was achieved in 17 of 26 (65.4%) rising to 72.7%, considering only those cases where the fistula could be accessed and Onyx was injected. The introduction of Onyx has improved the endovascular cure rate of DAVFs, particularly types III and IV. Advances in technology have made an endovascular approach the management of choice for the majority of DAVFs requiring treatment. Low complication rates are achievable.