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Hemorrhagic stroke
Original research
Onyx embolization for dural arteriovenous fistulas: a multi-institutional study
  1. Yangchun Li1,
  2. Stephanie H Chen2,
  3. Ridhima Guniganti3,
  4. Akash P Kansagra4,
  5. Jay F Piccirillo4,
  6. Ching-Jen Chen5,
  7. Thomas Buell6,
  8. Jason P Sheehan7,
  9. Dale Ding8,
  10. Giuseppe Lanzino9,
  11. Waleed Brinjikji10,
  12. Louis J Kim11,
  13. Michael R Levitt12,
  14. Isaac Josh Abecassis13,
  15. Diederik O Bulters14,
  16. Andrew Durnford15,
  17. W Christopher Fox16,
  18. Adam J Polifka17,
  19. Bradley A. Gross18,
  20. Samir Sur1,
  21. David J McCarthy18,
  22. Dileep R Yavagal19,
  23. Eric C Peterson20,
  24. Minako Hayakawa21,
  25. Colin Derdeyn22,
  26. Edgar A Samaniego23,
  27. Sepideh Amin-Hanjani24,
  28. Ali Alaraj25,
  29. Amanda Kwasnicki26,
  30. Fady T Charbel25,
  31. J Marc C van Dijk27,
  32. Adriaan RE Potgieser28,
  33. Junichiro Satomi29,
  34. Yoshiteru Tada30,
  35. Adib Abla31,
  36. Ryan Phelps32,
  37. Rose Du33,
  38. Pui Man Rosalind Lai33,
  39. Gregory J Zipfel34,34,
  40. Robert M Starke1,35
  41. On behalf of the Consortium for Dural Arteriovenous Fistula Outcomes Research
  1. 1 Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  2. 2 Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
  3. 3 Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
  4. 4 Department of Neurological Surgery, Washington University in St Louis, St Louis, Missouri, USA
  5. 5 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
  6. 6 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
  7. 7 Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  8. 8 Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
  9. 9 Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
  10. 10 Mayo Clinic Minnesota, Rochester, Minnesota, USA
  11. 11 Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
  12. 12 Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  13. 13 Department of Neurosurgery, University of Washington, Seattle, Washington, USA
  14. 14 Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
  15. 15 Department of Neurosurgery, University of Southampton, Southampton, Hampshire, UK
  16. 16 Department of Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
  17. 17 Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  18. 18 Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  19. 19 Department of Neurology and Neurosurgery, University of Miami, Miami, Florida, USA
  20. 20 Department of Neurological Surgery, University of Miami, Miami, Florida, USA
  21. 21 Division of Neurointerventional Surgery, Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, Iowa, USA
  22. 22 Department of Radiology and Interventional Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  23. 23 Department of Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  24. 24 Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
  25. 25 Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
  26. 26 Department of Neurosurgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
  27. 27 Department of Neurosurgery, Universitair Medisch Centrum Groningen, Groningen, Groningen, Netherlands
  28. 28 Department of Neurosurgery, University of Groningen, Groningen, Groningen, Netherlands
  29. 29 Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
  30. 30 Department of Neurosurgery, Tokushima University, Tokushima, Tokushima, Japan
  31. 31 Department of Neurosurgery, University of California, San Francisco, California, USA
  32. 32 Department of Neurosurgery, UCSF, San Francisco, California, USA
  33. 33 Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
  34. 34 Department of Neurological Surgery, Washington University, St Louis, Missouri, USA
  35. 35 Department of Radiology, University of Miami School of Medicine, Miami, Florida, USA
  1. Correspondence to Dr Robert M Starke, Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL 33146, USA; RStarke{at}med.miami.edu

Abstract

Background Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance.

Objective To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs.

Methods From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models.

Results A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0–129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes.

Conclusions In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.

  • fistula
  • liquid embolic material
  • complication
  • hemorrhage

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

http://dx.doi.org/10.1136/neurintsurg-2020-017109

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Twitter @DrMichaelLevitt, @wchrisfox, @Starke_neurosurgery

    • Contributors Conception: RMS. Data acquisition: all authors. Statistical analysis: YL. Drafting and critical revisions: all authors. Final approval and agreement to accountability: all authors.

    • Funding This research is in part supported by National Institutes of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute.

    • Competing interests RMS research is supported by the Neurosurgery Research and Education Foundation, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, and by the National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. The paper's contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. RMS has an unrestricted research grant from Medtronic and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, InNeuroCo, and Cerenovus. LJK reports funding support from the NINDS, consultant fees from Microvention, and stock ownership in Spi Surgical. MRL reports funding support from the National Institute of Neurological Disorders and Stroke, American Heart Association, Stryker, and Medtronic; consultant fees from Medtronic and Minnetronix; and equity interest from Proprio. AA reports funding support from the NIH, and consultant fees from Cerenovus. JFP reports consultant fees from Transonic. APK reports consultant fees from Medtronic and Penumbra. FTC reports serving as medical advisor for Bind-On Demand Health Insurance. DRY reports consultant fees from Medtronic, Cerenovus, and Rapid Medical and Neural Analytics. ECP reports consultant fees from Stryker Neurovascular, Penumbra, Medtronic, and Cerenovus, and stock ownership in RIST Neurovascular. BAG reports consultant fees from Microvention.

    • Provenance and peer review Not commissioned; externally peer reviewed.