Angioarchitectural predictors of failed endovascular treatment in high-grade dural arteriovenous fistulas

Predictors of endovascular treatment failure in high-grade dural arteriovenous fistulas (DAVFs) with cortical venous drainage (CVD) remain insufficiently characterized. This study aimed to identify angioarchitectural factors associated with failed endovascular treatment in DAVFs with CVD.

Patients with angiographically confirmed DAVFs with CVD who underwent first-line endovascular embolization in the DREAM-INI (Dural Arteriovenous Fistula Research and Management in China) database were retrospectively analyzed. Successful endovascular treatment was defined as durable complete obliteration without the need for additional surgery or radiosurgery. Baseline clinical and angioarchitectural characteristics were compared between successful and unsuccessful treatment groups. Logistic regression was used to identify predictors of treatment success.

A total of 415 patients were included. Successful endovascular treatment was achieved in 302 patients (72.8%), whereas 113 patients (27.2%) were classified as having unsuccessful treatment. On multivariable analysis, the presence of a middle meningeal artery feeder was independently associated with successful endovascular treatment. In contrast, pial arterial supply, venous congestion, and multiple fistulas were associated with lower odds of treatment success.

In DAVFs with CVD, specific angioarchitectural features are associated with the likelihood of durable cure after endovascular treatment. Middle meningeal artery feeders may facilitate successful embolization, whereas pial arterial supply, venous congestion, and multiple fistulas suggest more complex lesions that may require careful treatment planning and earlier consideration of multimodal strategies.