• Bradley A Gross, Felipe C Albuquerque, Karam Moon, and Cameron G McDougall.
• Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
• J Neurointerv Surg. 2017 Jan 1; 9 (1): 102-105.

Background/ObjectiveSpinal 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.MethodsWe reviewed our institutional database (January 1998-October 2015) for SDAVFs, performing an intention-to-treat analysis comparing endovascular-first and microsurgery-first approaches.ResultsA 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.ConclusionsOur 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.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

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