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Case series
Validation of an ‘endovascular-first’ approach to spinal dural arteriovenous fistulas: an intention-to-treat analysis
  1. Bradley A Gross,
  2. Felipe C Albuquerque,
  3. Karam Moon,
  4. Cameron G McDougall
  1. Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
  1. Correspondence to Dr Felipe C Albuquerque, c/o Neuroscience Publications; Barrow Neurological Institute, St Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013, USA; Neuropub{at}


Background/objective Spinal dural arteriovenous fistulas (SDAVFs) require pretreatment angiography; embolization can be performed in the same session. To validate this approach, obliteration and morbidity rates of ‘endovascular-first’ (embolization and microsurgery in the case of embolization failures) must be compared with rates for ‘microsurgery-first’ (microsurgical ligation without attempted embolization) approaches.

Methods We reviewed our institutional database (January 1998–October 2015) for SDAVFs, performing an intention-to-treat analysis comparing endovascular-first and microsurgery-first approaches.

Results A total of 71 patients underwent surgical and/or endovascular treatment for SDAVFs. All SDAVFs were ultimately occluded. Of 35 patients under consideration for an endovascular-first approach, radicular artery anatomy or anterior spinal artery embolization risk precluded attempting embolization in seven cases (20%). Among 28 patients undergoing embolization, angiographic non-opacification of the fistula was noted in 18 (64%). Fourteen patients had obliteration with excellent casting of the draining vein (50%) and did not undergo surgery. There were no significant differences in total complications (9% vs 11%; p=1.0) or permanent complications (3% vs 4%; p=1.0) after attempted endovascular and surgical treatment. Based on an intention-to-treat analysis, there were no significant differences in total complications (11% vs 14%; p=1.0), permanent complications (6% vs 3%; p=0.61), or the symptomatic resolution/improvement rate (80% vs 78%; p=1.0) between endovascular-first and microsurgery-first groups.

Conclusions Our results support attempted embolization of SDAVFs prior to consideration of microsurgery, allowing for a less invasive treatment option in the same session as diagnostic angiography.

  • Fistula
  • Liquid Embolic Material
  • Spine
  • Vascular Malformation

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  • Contributors Conception and design: BAG, FCA, KM and CGM. Drafting the article: BAG. Data acquisition, interpretation and analysis: BAG, FCA, KM and CGM. Critical revision of the article: BAG, FCA, KM and CGM. Statistical analysis: BAG. Study supervision: FCA, CGM. The authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Competing interests None declared.

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