DAVMs embolization

In case of high-risk (Borden II-III) DAVMs, particulate embolization as a sole treatment does not provide safe and permanent prevention from subsequent bleeding. If transarterial embolization is considered in such cases because neither surgery nor transvenous embolization is feasible or recommended, liquid embolics should be chosen (Fig. 4.21). Cyanoacrylate glue mixed with Lipiodol... 

Because transvenous embolization is not feasible for spinal lesions, transarterial embolization with glue is the treatment of choice for a spinal DAVM with an arterial feeder that allows safe and distal catheterization and does not supply the anterior spinal artery. Glue should be pushed until it reaches the draining vein (Fig. 4.18) (Cognard et al. 1996 Song et al. 2001). Clinical outcome seems to dependent on the severity of the symptoms at the time of treatment (Nagata et al. 2006). 

In studies analyzing results of transvenous embolization in series of 20-24 patients with nonselected DAVM, anatomical cure of 71%-88%, significant flow reduction of 12%, clinical cure in 83%-96%, and clinical improvement of 13% are reported (Urtasun et al. 1996 Roy and Raymond 1997). Patients in series of 10-13 with cavernous sinus DAVM treated via the superior ophthalmic vein approach experienced a 92%-100% clinical and anatomical cure rate and 15% transient worsening of the ocular symptoms (Miller et al. 1995 Quinones et al. 1997). 

Skeletonization, or removal of the sinus, requires extensive exploration of the dura and may be associated with significant blood loss and morbidity. Preoperative transarterial embolization is therefore recommended if that type of surgery is required. Such a combination is usually associated with excellent results an anatomical cure rate of 100%, with 0% permanent procedure-related morbidity and no mortality, is reported by several studies in series consisting of 17-34 patients with high-risk intracranial DAVM (Goto et al. 1999 Collice et al. 2000). 

The treatment of spinal DAVM by surgery is easy, safe, and effective and requires interruption of the draining vein at its dural entrance only (Anson and Spetzler 1992). Therefore, embolization of spinal DAVM should be offered only if the feeding pedicle provides a safe approach to a position close to the fistula site and it does not give rise to radiculomedullary branches supplying the anterior spinal artery. If there is a risk of reflux into the anterior spinal artery, surgery is significantly safer and should be performed. 

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