Combined Endovascular and Surgical Treatment of Type I Spinal Dural Arteriovenous Fistulas

Abstract

Introduction Spinal dural arteriovenous fistulas (SDAVFs) are rare but most common form of spinal vascular malformations, accounting for approximately 70% of all such lesions. They are low-flow vascular shunts fed by radicular arteries. Patients most often present with myelopathy. The presumed pathophysiological mechanism is venous hypertension and congestion of the cord with edema. We present our experiences and results in combined endovascular and surgical treatment of type I SDAVFs. Patients and Methods We conducted a retrospective review of prospectively collected data from patients with a diagnosis of SDAVFs who underwent treatment at University Hospital Centre Rebro Zagreb between January 2012 and June 2014. The complication and recurrence rates from clinical and imaging follow-up in these patients are analyzed. Results A total of 14 patients with a diagnosis of SDAVFs were treated in our institution during the analyzed period. Of these, 12 patients underwent endovascular embolization as first-line therapy. Onyx was used in 1 patient and NBCA in 11 patients. Two patients underwent surgical ligation as the initial therapeutic procedure. Patients in both groups showed significant improvement in clinical status after treatment on the Aminoff-Logue Scale. One patient in the endovascular group developed spinal infarction because of the accidental embolization of posterior spinal artery. Six patients in embolization group had recurrence of the fistula during the course of follow-up requiring surgical ligation. Two patients in the surgical group had recurrence of fistula during the course of follow-up and were reoperated. Conclusion Although most type I SDAFs are amenable to endovascular embolization, microsurgical obliteration as first option is indicated in specific anatomic situations and usually the only solution for recurrent cases. The combined endovascular and microsurgical approach offers best results after careful selection of patients based on imaging.