The risk-to-benefit profile of treating an unruptured high-grade dural arteriovenous fistula (dAVF) is not clearly defined. The aim of this multicenter retrospective cohort study was to compare the outcomes of different interventions with observation for unruptured high-grade dAVFs.
The authors retrospectively reviewed dAVF patients from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with unruptured high-grade (Borden type II or III) dAVFs were included and categorized into four groups (observation, embolization, surgery, and stereotactic radiosurgery [SRS]) based on the initial management. The primary outcome was defined as the modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were good outcome (mRS scores 0–2) at final follow-up, symptomatic improvement, all-cause mortality, and dAVF obliteration. The outcomes of each intervention group were compared against those of the observation group as a reference, with adjustment for differences in baseline characteristics.
The study included 415 dAVF patients, accounting for 29, 324, 43, and 19 in the observation, embolization, surgery, and SRS groups, respectively. The mean radiological and clinical follow-up durations were 21 and 25 months, respectively. Functional outcomes were similar for embolization, surgery, and SRS compared with observation. With observation as a reference, obliteration rates were higher after embolization (adjusted OR [aOR] 7.147, p = 0.010) and surgery (aOR 33.803, p < 0.001) and all-cause mortality was lower after embolization (imputed, aOR 0.171, p = 0.040). Hemorrhage rates per 1000 patient-years were 101 for observation versus 9, 22, and 0 for embolization (p = 0.022), surgery (p = 0.245), and SRS (p = 0.077), respectively. Nonhemorrhagic neurological deficit rates were similar between each intervention group versus observation.
Embolization and surgery for unruptured high-grade dAVFs afforded a greater likelihood of obliteration than did observation. Embolization also reduced the risk of death and dAVF-associated hemorrhage compared with conservative management over a modest follow-up period. These findings support embolization as the first-line treatment of choice for appropriately selected unruptured Borden type II and III dAVFs.
Correspondence Jason P. Sheehan: University of Virginia Health System, Charlottesville, VA. email@example.com.
INCLUDE WHEN CITING Published online September 10, 2021; DOI: 10.3171/2021.1.JNS202799.
Disclosures Dr. Kansagra reports consultant fees from Medtronic and Penumbra and non–study-related clinical or research effort from MicroVention and Medtronic. Dr. Lanzino is a consultant for Superior Medical Editing and Nested Knowledge. Dr. Kim reports funding support from the NINDS, consultant fees from MicroVention, and stock ownership in SPI Surgical. Dr. Levitt reports funding support from the NINDS, AHA, Stryker, and Medtronic, and consultant fees from Medtronic, Minnetronix, and Metis Innovative; and ownership in Synchron, Cerebrotech, and Proprio. Dr. Polifka is a consultant for DePuy Synthes. Dr. Gross reports consultant fees from MicroVention and Medtronic. Dr. Derdeyn reports ownership in Pulse Therapeutics; is a consultant for Penumbra, Rapid Medical, and NoNo; and received clinical or research support for this study from Siemens Healthineers. Dr. Alaraj reports funding support from the NIH, and consultant fees from Cerenovus and Siemens. Dr. Starke reports funding support from NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, and the NIH, and consultant fees from Penumbra, Abbott, Medtronic, and Cerenovus.
GrossBA, AlbuquerqueFC, MoonK, McDougallCG. Evolution of treatment and a detailed analysis of occlusion, recurrence, and clinical outcomes in an endovascular library of 260 dural arteriovenous fistulas. J Neurosurg. 2017;126(6):1884–1893.
GrossBA, AlbuquerqueFC, MoonK, McDougallCG. Evolution of treatment and a detailed analysis of occlusion, recurrence, and clinical outcomes in an endovascular library of 260 dural arteriovenous fistulas. J Neurosurg. 2017;126(6):1884–1893.)| false