Three-dimensional angioarchitecture and microsurgical treatment of arteriovenous fistulas at the craniocervical junction.

Digital subtraction angiography (DSA) is the gold standard for diagnosing vascular malformations; however, difficulties are associated with visualizing the angioarchitecture of arteriovenous fistulas at the craniocervical junction (CCJ AVFs) using DSA because of their complex regional neurovascular anatomy. The present study evaluated the application of 3-dimensional computer graphics (3D CG) to the surgical planning of CCJ AVFs. Six patients with CCJ AVFs who underwent microsurgery and/or endovascular treatment were included. The results of DSA and 3D CG were compared in the last 3 patients. The visibility of important anatomical structures were evaluated using visibility grading scores. Clinical outcomes were assessed based on the rate of occlusion of AVFs, surgical complications, neurological status, and recurrence in long-term follow-ups. The 3D CG images could combine arteries, veins, the spinal cord and dura mater in one single picture to evaluate the anatomy of CCJ AVFs. The image interpretation of vascular structures, particularly narrow arterial feeders, was significantly better using 3D CG than DSA (overall visibility scores, 97% vs 51%, p = 0.001). In all patients, the complete occlusion of AVFs was achieved by microsurgery except for 2 patients without surgical planning with 3D CG. Postoperatively, the neurological status of all patients improved or stabilized without the recurrence of AVFs (median, 5.4 years). 3D CG may help to improve the quality of the microsurgical procedures in complex AVFs. However, it should be used as a complementary diagnostic modality rather than the alternative of DSA because 3D CG has no hemodynamic information at this time.