Eighteen-year journey in endovascular management of cavernous sinus DAVFs: advances, outcomes, and lessons learned

Purpose: This study presents a long-term single-centre experience with CS-DAVFs and discusses the historical progression, current state, and future directions of endovascular treatment. Methods: We retrospectively reviewed all patients with CS-DAVFs endovascularly treated at our institution between 2006 and 2024. We evaluated clinical presentation, imaging findings, endovascular treatment techniques, and clinical improvement. Results: 63 patients underwent 68 endovascular procedures. 49 patients (72%) underwent transvenous procedures through the inferior petrosal sinus or ophthalmic veins. 39 fistulas (57%) were occluded using liquid embolic agents (LEAs) alone or in combination with coils. Eight patients (12%) required the injection of LEAs in the superior pharyngeal branch of the APA to reach the complete occlusion of the fistula. In 4 cases, the vascular anatomy of the fistula required the direct puncture of the draining vein. In 46 cases (68%), the fistula was successfully occluded using coils. Complete occlusion was achieved in 52 of the cases (77%), but two cases (3%) had fistula recurrence after the first treatment. We found one complication of the endovascular procedure in the study population. The median imaging follow-up time was 12 months (range 2-135); the median clinical follow-up was 32 months (range 1.5-194). 60 Patients (95%) showed persistent clinical improvement. Conclusions: Endovascular occlusion is the gold standard for CS-DAVFs, with high rates of occlusion and few complications. Continued advancements in techniques and devices are essential to improve outcomes and reduce complications.