Future Is Ven(o)us: A 5-Year Narrative Update on the Venous Route for Therapeutics in Neurointervention

During the past 5 years, transvenous techniques have rapidly expanded the neurointerventional landscape, offering new diagnostic and therapeutic strategies for a range of cerebrovascular conditions. This narrative review synthesizes contemporary evidence and technical advances across multiple venous applications, including transvenous embolization for AVMs and dural fistulas, treatment of CSF-venous fistulas, and venous sinus stent placement for pulsatile tinnitus, intracranial hypertension, and skull base leaks. Recent data underscore high efficacy rates and favorable safety profiles in carefully selected patients, often matching or surpassing traditional arterial approaches. Innovations such as fetal vein of Galen embolization, vein-targeted brain-computer interface implantation, and endovascular CSF shunting exemplify the therapeutic versatility of venous access. However, procedural challenges, such as venous anatomy, access, and embolic control, require meticulous planning and advanced skill sets. Trials like TATAM and DIVE-IIN are and will shape evidence-based indications for transvenous therapy. With expanding indications and growing operator expertise, the venous route is evolving from a niche adjunct into a cornerstone of neurovascular care.