Future is Ven(o)us: A 5-year narrative update on the venous route for therapeutics in Neurointervention

Over the past five years, transvenous (TV) techniques have rapidly expanded the neurointerventional landscape, offering new diagnostic and therapeutic strategies for a range of cerebrovascular conditions. This narrative review synthesizes contemporary evidence and technical advances across multiple venous applications, including TV embolization for arteriovenous malformations and dural fistulas, treatment of cerebrospinal fluid-venous fistulas, and venous sinus stenting for pulsatile tinnitus, intracranial hypertension, and skull-base leaks. Recent data underscore high efficacy rates and favorable safety profiles in carefully selected patients, often matching or surpassing traditional arterial approaches. Innovations such as fetal vein of Galen embolization, vein-targeted brain-computer interface implantation, and endovascular cerebrospinal fluid shunting exemplify the therapeutic versatility of venous access. However, procedural challenges, such as venous anatomy, access, and embolic control, require meticulous planning and advanced skillsets. Trials like TATAM and DIVE-IIN are and will shape evidence-based indications for TV therapy. With expanding indications and growing operator expertise, the venous route is evolving from a niche adjunct into a cornerstone of neurovascular care.ABBREVIATIONS: bAVM(s)＝ brain arteriovenous malformation(s); CVF(s)＝ cerebrospinal fluid-venous fistula(s); CVT＝ cerebral venous thrombosis; DAVF(s)＝ dural arteriovenous fistula(s); EVT＝ endovascular therapy; EVOH＝ ethylene-vinyl alcohol copolymer; IIH＝ idiopathic intracranial hypertension; JR-NET3＝ Japanese Registry of NeuroEndovascular Therapy; PT＝ pulsatile tinnitus; RPCT＝ retrograde pressure-cooker technique; SIH＝ spontaneous intracranial hypotension; sCSFL＝ spontaneous cerebrospinal fluid leak; SSWA＝ sigmoid sinus wallabnormality/abnormalities; TV＝ transvenous; TVE＝ transvenous embolization; VSS＝ venous sinus stenting.