Comparative Efficacy and Safety of Endovascular Versus Surgical Treatment in Spinal Dural Arteriovenous Fistulas : A Systematic Review and Meta-analysis.

Study design: Systematic review and meta-analysis.

Objective: This study aims to compare the efficacy and safety of surgical and endovascular treatments for SDAVFs.

Summary of background data: Spinal dural arteriovenous fistulas (SDAVFs) result from an abnormal connection between the radiculomeningeal artery and the radicular vein, leading to venous hypertension and potential neurological damage. The two primary treatment strategies are surgical closure and endovascular obliteration of the fistula.

Methods: PubMed, Scopus, and Web of Science databases were searched from inception to July 2024. We defined the successful treatment as fistula occlusion with sufficient embolic material penetration or obliteration during surgery.

Results: A total of 1192 articles were identified, with 40 studies meeting the inclusion criteria, comprising 1818 patients (surgical: 804, endovascular: 1014). The surgical group demonstrated higher rates of complete occlusion at the last follow-up (96.8%, 363/375) compared with the endovascular group (72.5%, 470/648) (OR: 0.16; CI: 0.09-0.28, P < 0.01). Surgical treatment also had higher successful treatment rates (97.5%, 392/402) compared with endovascular treatment (66.7%, 529/793) (OR: 0.11; CI: 0.06- 0.19, P < 0.01). Recurrence rates were lower in the surgical group (OR: 6.04; CI: 3.45-10.57, P < 0.01) and retreatment rates were also lower (OR: 7.16; CI: 4.11-12.48, P < 0.01). Initial treatment failure was significantly higher in the endovascular group (32.2%, 329/1023) compared with the surgical group (2.3%, 19/804) (OR: 8.97; CI: 5.56-14.45, P < 0.01).

Conclusions: Surgical treatment for SDAVFs achieves higher rates of complete occlusion and successful treatment compared with endovascular treatment, with lower rates of recurrence, retreatment, and initial treatment failure. Although both treatments show similar improvements in neurological status and periprocedural complications, surgery remains the preferred approach for definitive results. Treatment decisions should be individualized based on patient-specific factors and anatomical characteristics. Further research is needed to confirm these results.