Transvenous approach: a promising strategy for endovascular treatment of tentorial dural arteriovenous fistulas

OBJECTIVE: Tentorial dural arteriovenous fistulas (TDAVFs) are uncommon, high-risk intracranial vascular malformations characterized by severe clinical courses. Transarterial embolization (TAE) has been widely recognized as the primary treatment modality. Nevertheless, limited data exist regarding the safety and efficacy of transvenous embolization (TVE). The current study reports a comparative analysis of TAE and TVE in a consecutive TDAVF cohort, providing detailed insights into both clinical and angiographic outcomes. METHODS: A retrospective cohort analysis was conducted on 53 patients with TDAVFs treated at the authors' institution between January 2016 and March 2024. Patients were categorized into TAE and TVE groups based on the specific procedure performed on each individual. RESULTS: A total of 53 patients who underwent 59 procedures were included in this study. Onyx served as the exclusive liquid embolic agent in all procedures. TVE demonstrated superior immediate complete occlusion rates compared to TAE (92.3% vs 56.8%, p = 0.04), with sustained long-term occlusion at follow-up (100% vs 65.7%, p = 0.04). Complication rates were comparable (15.4% for TVE vs 6.8% for TAE, p = 0.69), with no permanent neurological deficits. Multivariate analysis identified TVE (adjusted OR 0.096, p = 0.048) and fewer feeding arteries (adjusted OR 0.688, p = 0.009) as independent predictors of immediate occlusion. CONCLUSIONS: In TDAVFs characterized by accessible venous routes, TVE exhibits superior angiographic outcomes compared to TAE, while maintaining comparable complication profiles. The wire-loop technique and dual-microcatheter strategy are essential for achieving reliable venous access. Although TAE remains effective for the majority of TDAVFs, TVE may be a promising initial strategy for lesions with favorable venous accessibility.