Too late to save: The national surge in ruptured arteriovenous malformations and the decline in endovascular utilization from 2016 to 2022

Abstract

Introduction: The ARUBA trial has influenced a shift towards more conservative management of small, unruptured cerebral arteriovenous malformations (AVMs), leading to less aggressive treatment approaches among neurointerventionalists. However, with evolving endovascular techniques, it is important to assess whether national practice changes have impacted rupture rates and outcomes. Methods: Data from the Nationwide Inpatient Sample (NIS) for 2016–2022 regarding clinical characteristics, cost, morbidity, and mortality endovascularly treated AVMs was analyzed. Trends were evaluated using multivariable regression modeling, controlling for patient and hospital characteristics. Results: A total of 8,935 patients underwent endovascular treatment for cerebral AVMs (6,500 unruptured and 2,435 ruptured). Endovascular treatment for unruptured AVMs declined significantly from 1195 cases in 2016 to 780 in 2022 (−34.7%, p = 0.020). Over the same period, the proportion of AVMs presenting ruptured increased from 15.7% to 25.7%, a 63.7% relative increase (p = 0.015). Multivariable analysis confirmed rising odds of rupture over time among endovascularly treated patients (OR = 1.12, 95% CI 1.00–1.25, p = 0.042). Among 11,205 ruptured AVM patients, the in-hospital mortality rate of thosewho did not undergo surgery rose 67.2% over time (6.7% in 2016 to 11.2% in 2022, p = 0.006). Conclusion: The study reveals an increase in the probability of patients presenting with ruptured AVMs and being observed with a consequent increase in in-hospital mortality. This may be an unintended consequence of less aggressive strategies following the ARUBA trial, prompting a need to reevaluate current management techniques amidst rising costs, morbidity, and mortality. © 2025 Elsevier B.V., All rights reserved.