How well do we understand the anatomy of dural arteriovenous fistulas (dAVFs)? Where among the myriad vessels we see increasingly well on ever-advancing MR, CT, and volumetric angiographic images is the “seat of disease”?
Our paper reviews existing literature and our experience, suggesting that many transverse/sigmoid dAVFs consist of 1, or at most a limited number of, direct arteriovenous connection(s). The seemingly complex angioarchitecture of these lesions is proposed to represent myriad artery-to-artery anastomoses, converging upon a common collector vessel within the wall of the dural sinus.
This collector represents a final common arterial channel, with 1 (or a limited set of) opening(s) into the dural sinus. The site of fistulous communication thus involves a discrete point in the sinus wall where this common artery empties into the sinus, an arrangement best appreciated in lower grade fistulas, when the true sigmoid sinus is still intact.
This view lends itself to the possibility of highly targeted, “magic bullet” occlusion of this common channel and its connection with the true sinus.
When possible, such superselective treatments can safely and effectively occlude the fistula without unnecessary, expensive, lengthy, and potentially hazardous permeation of arterial territories remote from the site of shunting or the sacrifice of major venous structures not directly involved in the shunt pathology.
This kind of angioarchitecture is particularly evident in lower grade fistulas, where sinus preservation and low treatment morbidity are especially critical.