Compression therapy and embolization through feeding arteries (femoral transarterial embolization) can ameliorate symptoms related to dural AV fistulas, particularly those in certain anatomical locations such as the cavernous sinus.2,3 Unless the fistula is completely closed by embolization, however, collateral supply may develop and the fistula will recanalize. Occlusion of feeding vessels in an initial procedure may complicate or prevent later treatment because transarterial approaches may no longer be possible. Complete obliteration of dural AV fistulas by transarterial embolization may not be possible in locations such as the superior sagittal sinus, vein of Galen, or straight sinus. There is a 15% rate of major morbidity and mortality for surgical therapy of dural AV fistulas in the transverse and sigmoid sinuses.11 Surgery of these lesions may cause massive blood loss.
Over the past 8 years, 88 patients were evaluated for treatment of symptomatic dural AV fistulas by transvascular techniques. Sixteen patients either failed to respond to standard transvascular treatment or had lesions in anatomical locations that made treatment too hazardous to attempt by this approach. These patients were treated with a combined approach using both endovascular and neurosurgical techniques. The methods used and the results of therapy are reported here.
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