Background and purpose Endovascular treatment is an accepted choice for intracranial pial and dural arteriovenous fistulas (PAVF/DAVF). We assessed the technical feasibility, safety and efficacy of the endovascular approach as monotherapy for difficult and complex cases.

Methods Since June 2006 to Dec 2009, of 68 patients with cerebral AVMs treated, 20 cases were DAVF and six were PAVF. 10 cases presented with hemorrhage, two cases with seizures, eight cases with headache and six cases truly incidental. 16 cases were treated with a transarterial strategy while seven lesions were treated using a transvenous approach (retrograde technique). Clinical and radiological outcome were assessed and mid term follow-up is presented. Special consideration was taken into account with regard to anatomical tips and adverse events.

Results Fistula occlusion (technical success) of 97% was achieved. Undesired distal embolization was registered in one case. In two cases we had microcatheter retention. One case of recurrence after occlusion. None case presented rebleeding during follow-up.

Conclusion Current microsystems can be safely maneuvered through severely tortuous arterials and venous vessels although technically demanding to advance while a ‘retrograde’ technique is carried out. The combined strategy was associated with high rates of occlusion. Although immediate and mid term angiographic results are promising, long term angiographic and clinical follow-up is essential to determine occlusion stability and clinical outcome