Transvenous embolization as the primary therapy for arteriovenous fistulas of the lateral and sigmoid sinuses

We report on the evolution in one institution from transarterial embolization for the treatment of dural arteriovenous fistulas of the lateral and sigmoid sinuses to the safer and more durable technique of transvenous endovascular therapy for the majority of these lesions.

Arterial, venous, and combined embolizations were performed for 24 fistulas of the lateral and sigmoid sinuses between August 1991 and December 1996. The patients were followed up clinically for 2 to 63 months, with a mean follow-up period of 30 months.

Nine patients had arterial embolization without transvenous treatment: five of the nine had angiographic and clinical obliteration of their fistulas; two of the nine, with unusual lesions, required surgery; and the remaining two had recurrences and were not retreated. Seven patients had both arterial embolization and coil embolization (packing) of the dural sinuses, four after arterial embolization had failed to cure the lesions; in all seven, the fistulas were obliterated angiographically and clinically. Eight patients had only transvenous coil embolization of the dural sinuses; all eight were cured. One patient had minimal arterial embolization during the primary venous embolization procedure. Complications occurred in two patients, both related to arterial embolization with ethanol.

Our experience suggests that arterial embolization of dural arteriovenous fistulas of the lateral and sigmoid sinuses is associated with a low cure rate and high rate of recurrence, whereas transvenous endovascular packing of the involved segment of the sinus results in a high cure rate that obviates arterial embolization or surgical excision in most cases.