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Published on: July 11, 2019
Systemic Cardiovascular Factors and Outcomes in Dural Arteriovenous Fistulas: Insights From the CONDOR Registry
Alejandro N Santos1, Sai Sanikommu1, Bashar Dawoud1
1Department of Neurological Surgery, University of Miami School of Medicine, FL (A.N.S., S.S., B.D., R.M.S.).
Insights
Hemorrhagic risk in dural arteriovenous fistulas (dAVFs) is linked to venous anatomy and male sex. Antithrombotic therapy may reduce bleeding risk, while baseline function impacts outcomes post-treatment.
Area of Science:
- Neurology
- Vascular Surgery
- Radiology
Background:
- Hemorrhagic risk in dural arteriovenous fistulas (dAVFs) is primarily linked to venous anatomy.
- The role of systemic cardiovascular factors and their medical management in dAVF hemorrhage is not well-defined.
Purpose of the Study:
- To investigate the association between cardiovascular risk factors, antithrombotic use, and hemorrhagic presentation in dAVFs.
- To evaluate the impact of these factors on angiographic obliteration and early functional outcomes after treatment.
Main Methods:
- Analysis of 1350 adult intracranial dAVF cases from an international registry (1990-2017).
- Collection of data on demographics, comorbidities, antithrombotic use, angioarchitecture, treatments, and outcomes.
- Application of univariable and multivariable logistic regression for statistical analysis.
Main Results:
- Hemorrhage (27.8%) strongly correlated with high-grade dAVFs and male sex; antithrombotic therapy showed a protective association.
- Cardiovascular risk factors lacked independent association with bleeding.
- Angiographic obliteration was achieved in 73.5% of patients; baseline functional status was the strongest predictor of 90-day outcomes.
Conclusions:
- Venous angioarchitecture, male sex, and antithrombotic therapy are key factors in dAVF hemorrhagic presentation.
- Angiographic obliteration rates are high, especially with surgical treatment.
- Baseline functional status is the primary determinant of early functional outcomes post-treatment.
Background:
Hemorrhagic risk in dural arteriovenous fistulas (dAVFs) is largely determined by venous anatomy, but the contribution of systemic cardiovascular factors and their medical therapy remains poorly defined. This study examined associations between cardiovascular risk factors and antithrombotic use and hemorrhagic presentation, angiographic obliteration, and early functional outcomes after treatment.
Methods:
We analyzed 1350 adults with intracranial dAVFs from the international Consortium for Dural Arteriovenous Fistula Outcomes Research registry, which retrospectively accrued cases across 14 centers in 4 countries between 1990 and 2017. Demographics, cardiovascular comorbidities, antithrombotic use, angioarchitectural features, treatment strategies, and follow-up outcomes were collected from prospectively maintained databases. Primary end points were hemorrhagic presentation, angiographic obliteration, and 90-day functional status after treatment. Univariable and multivariable logistic regressions were performed with model-specific adjustments.
Results:
Hemorrhage occurred in 375 patients (27.8%) and was most strongly associated with high-grade dAVF classification and male sex; antithrombotic therapy was associated with lower odds of hemorrhagic presentation. Other cardiovascular risk factors showed no independent relationship with bleeding. Angiographic obliteration was achieved in 621 of 845 patients (73.5%). Hemorrhagic onset, high dAVF grade, and surgical treatment were independently associated with angiographic obliteration, whereas smoking and embolization demonstrated only nonsignificant trends after adjustment. At 90 days, 934 patients (88.9%) were functionally independent. Baseline modified Rankin Scale score was the strongest factor associated with 90-day functional outcome, while neither cardiovascular comorbidities nor treatment modality independently influenced functional status.
Conclusions:
In this large multicenter dAVF cohort, hemorrhagic presentation was most strongly associated with venous angioarchitecture. Male sex and antithrombotic therapy were also independently associated with hemorrhagic presentation. Angiographic obliteration was common, particularly among surgically treated lesions, and 90-day functional outcome was most strongly associated with baseline functional status.