Comparison of superior ophthalmic vein approach and inferior petrosal sinus recanalization in the treatment of cavernous sinus dural arteriovenous fistula: a multicenter retrospective study

Background Cavernous sinus dural arteriovenous fistulas (CS-DAVFs) present significant treatment challenges when the inferior petrosal sinus (IPS) is not opacified during cerebral angiography. The consistently visible superior ophthalmic vein (SOV) offers a promising alternative, though it has yet to be fully evaluated in large-scale studies. Methods This retrospective, case–control study was conducted between May 2017 and October 2024. Data collection for this multicenter, population-based study took place across eight tertiary referral centers. Eligible patients diagnosed with CS-DAVF and non-visualized IPS were treated either via the transvenous SOV approach or the IPS recanalization approach. Results Of 178 eligible cases, 70 cases (39.33%) were treated using the transvenous SOV approach, while 108 cases (60.67%) underwent the transvenous IPS approach. The initial treatment success rate was significantly higher in the SOV group compared with the IPS group (91.43% vs 75.93%; OR 3.38, 95% CI 1.30 to 8.35, P=0.01). The overall complication rate was 1.43% in the SOV group and 2.78% in the IPS group (OR 0.51, 95% CI 0.04 to 3.47, P>0.99). After classifying the SOV approach into simple and complex types, the SOV-simple type further demonstrated significant advantages, including shorter average operation times (126.20±46.99 min, P=0.02) and a higher initial treatment success rate (95.65%, P=0.003) compared with the IPS group. Conclusion The SOV approach is recommended as a first-line treatment for CS-DAVF patients with ‘invisible’ IPS.