Utilizing the Ascending Pharyngeal Artery for Onyx Embolization in Cranial Dural Arteriovenous Fistulas: A Retrospective Analysis

Objective: This retrospective study evaluates our experience with transarterial embolization (TAE) of dural arteriovenous fistulas (dAVFs) using the ascending pharyngeal artery (APA), considering its selective application as a route for the treatment. Methods: We performed a retrospective analysis of medical records and radiologic data of all patients who underwent TAE through the APA at our institution from January 2009 to April 2021. Results: We identified 305 patients with cranial dAVFs treated endovascularly at our center, focusing on 11 cases (3.6%) where the APA was used for Onyx embolization. Of the 11 dAVFs, five (45%) were completely occluded, three (27%) showed residual shunt but cortical venous reflux disappeared, and three (27%) showed decreased shunt flow but persistent cortical venous reflux. Cranial nerve palsy occurred in two of the cases in which TAE was performed with the jugular branch and hypoglossal branch of the neuromeningeal trunk, which partially improved over 4 to 6 months. No new instances of infarction or hemorrhage were noted on subsequent magnetic resonance angiography. Conclusion: Transarterial Onyx embolization through the APA could be a limited option reserved for cases where embolization using other branches is challenging or carries a high risk of incomplete treatment. While embolizing through the jugular and hypoglossal branches of the APA neuromeningeal trunk requires greater caution, selecting the posterior meningeal artery or pharyngeal trunk appears to be associated with a lower risk. A comprehensive understanding of angiography is crucial for identifying cases suitable for this approach and those with a higher risk of complications.