Introduction With the introduction of Onyx, transarterial embolization has become the most common endovascular approach for dural arteriovenous fistulas (dAVF)s, often via the middle meningeal or occipital arteries. The ascending pharyngeal artery (APA) is a less frequently explored transarterial route as a result of its small caliber, potential anastomoses to the internal carotid and vertebral arteries, and its vital supply to lower cranial nerves.

Methods We reviewed our endovascular database (January 1996 – March 2016) for cranial dAVFs, evaluating dAVF characteristics and embolization results for those treated transarterially via the APA.

Results Of 267 endovascularly-treated dAVFs, 68 had APA supply (25%). This included all marginal sinus dAVFs (11/11), 43% of transverse/sigmoid (37/86), 26% of tentorial/petrosal (12/47), 20% of torcular (3/15), and 8% of cavernous sinus (5/60) dAVFs. Of 68 dAVFs with APA supply, embolization was carried out via this pedicle in eight (12%), and seven were ultimately occluded.There were no complications, including no post-treatment cranial neuropathies or radiographic evidence of nontarget embolization. For five dAVFs, the APA was selected as the initial pedicle for embolization (marginal sinus, n = 2; distal sigmoid, n = 1; cavernous, n = 1, tentorial, n = 1). In 4/5 cases, dAVF occlusion was achieved via the initial APA feeding artery pedicle. In one case, near complete, stagnant occlusion was achieved; adjunctive embolization of a single additional MMA pedicle was performed. In three other cases of complex transverse/sigmoid dAVF, the APA was utilized after multiple attempts via middle meningeal and occipital artery pedicles. Occlusion was not achieved transarterially; two of the three dAVFs were ultimately occluded transvenously.

Conclusion In rare, select cases, the APA is an excellent route for transarterial embolization of cranial dAVFs.

Disclosures B. Gross: None. F. Albuquerque: None. K. Moon: None. C. McDougall: None.