Stratified assessment of treatment approach for craniocervical junction arteriovenous fistulas: a multicenter cohort study and literature review

OBJECTIVE Craniocervical junction arteriovenous fistulas (CCJ-AVFs) are complex vascular shunts that present a challenge for treatment. The aim of this study was to compare the clinical outcomes of microsurgery and endovascular embolization for CCJ-AVFs and to determine whether the treatment approach affected the obliteration rate and neurological improvement. METHODS The authors conducted a retrospective analysis of 64 patients who had undergone microsurgery or endovascular embolization for CCJ-AVF at one of two neurosurgical centers from January 2014 to February 2022. Additionally, a pooled analysis of 68 patients from 38 studies was performed. Baseline characteristics, angioarchitectural features, and clinical outcomes were compared between two treatment groups. A subgroup analysis of CCJ-AVFs with carotid artery (CA) feeders was also performed. RESULTS In the multicenter cohort, the complete obliteration rate was 95.1% with microsurgery, 81.8% with embolization via the CA, and 50.0% with embolization via the vertebral artery (VA). After adjusting for baseline and confounding features, the occlusion rate was significantly lower in the VA embolization group (adjusted OR 41.06, 95% CI 2.37–711.9, p = 0.01). No new-onset infarctions occurred in the microsurgical group, whereas 1 patient each in the CA and VA embolization groups experienced posttreatment infarction. Microsurgery demonstrated a neurological improvement rate similar to that in the CA embolization group (65.9% vs 63.6%, respectively). In the subgroup analysis of CCJ-AVF with CA feeders in the multicenter cohort, the occlusion rate and neurological improvement in the CA embolization group were comparable to those in the microsurgery group. The subgroup analysis in the pooled analysis revealed complete obliteration rates of 100.0% in the microsurgical group, 88.9% in the CA embolization group, and 66.7% in the VA embolization group. CONCLUSIONS This study supports microsurgery as the best treatment modality for CCJ-AVFs, exhibiting the highest rates of complete obliteration. Conversely, embolization via the VA can result in a lower occlusion rate and less neurological improvement. In CCJ-AVFs with CA feeders, embolization via the CA can be a safe and effective alternative to microsurgery.