Eighteen-year journey in endovascular management of cavernous sinus DAVFs: advances, outcomes, and lessons learned

This study presents a long-term single-centre experience with CS-DAVFs and discusses the historical progression, current state, and future directions of endovascular treatment.

We retrospectively reviewed all patients with CS-DAVFs endovascularly treated at our institution between 2006 and 2024. We evaluated clinical presentation, imaging findings, endovascular treatment techniques, and clinical improvement.

63 patients underwent 68 endovascular procedures. 49 patients (72%) underwent transvenous procedures through the inferior petrosal sinus or ophthalmic veins. 39 fistulas (57%) were occluded using liquid embolic agents (LEAs) alone or in combination with coils. Eight patients (12%) required the injection of LEAs in the superior pharyngeal branch of the APA to reach the complete occlusion of the fistula. In 4 cases, the vascular anatomy of the fistula required the direct puncture of the draining vein. In 46 cases (68%), the fistula was successfully occluded using coils. Complete occlusion was achieved in 52 of the cases (77%), but two cases (3%) had fistula recurrence after the first treatment. We found one complication of the endovascular procedure in the study population. The median imaging follow-up time was 12 months (range 2-135); the median clinical follow-up was 32 months (range 1.5-194). 60 Patients (95%) showed persistent clinical improvement.

Endovascular occlusion is the gold standard for CS-DAVFs, with high rates of occlusion and few complications. Continued advancements in techniques and devices are essential to improve outcomes and reduce complications.