Transvenous embolization of a dural arteriovenous fistula of the cavernous sinus through the contralateral pterygoid plexus

Transvenous embolization of dural carotid-cavernous fistulae with transfacial catheterization through the superior ophthalmic vein

OBJECTIVE

We report our experience gaining access to the cavernous sinus via transfacial catheterization of the superior ophthalmic vein through the angular or retromandibular vein. We evaluate the viability of this approach as a safe and convenient alternative pathway for transvenous embolization of the cavernous sinus.

METHODS

This is a retrospective study of 98 patients with symptomatic dural carotid-cavernous fistulae from two major regional hospitals in Hong Kong. All 98 patients presented with one or more ocular symptoms. Seventy-four transvenous embolization procedures were performed on 71 patients. Transvenous access to the cavernous sinus was attempted through various pathways, one by one, until the cavernous sinus was successfully catheterized.

RESULTS

The overall technical success rate of transvenous embolization of dural carotid-cavernous fistulae in our study was 64 out of 74 patients (86.5%). Had we not used the technique of transfacial catheterization, the technical success rate would have been 53 out of 74 patients (71.6%). After adoption of the transfacial approach, the technical success rate of transvenous embolization became 64 out of 64 patients (100%). Residual symptoms occurred in eight patients. Two patients developed transient VIth cranial nerve palsy after transvenous embolization for 1 and 2 months, respectively. Otherwise, there were no complications.

CONCLUSION

Transfacial catheterization through the superior ophthalmic vein is a safe and effective approach and provides a convenient alternative pathway for transvenous embolization of dural carotid-cavernous fistulae when cannulation of the inferior petrosal sinus is not successful, thereby increasing the technical success rate.

Transvenous embolization of cavernous sinus dural arteriovenous fistula with onyx-18 and platinum coils. A technical note

We describe a patient with dural arterial venous fistula of the cavernous sinus causing occulomotor palsy and chemosis. The fistula was successfully treated via transvenous approach with Onyx-18 and detachable platinum coils.

Transvenous embolization of a dural arteriovenous fistula of the laterocavernous sinus through the pterygoid plexus

We present a novel access for transvenous embolization of a dural arteriovenous fistula of the laterocavernous sinus through the external jugular vein and the pterygoid plexus. The anatomy of the laterocavernous sinus is reviewed, and its clinical implications discussed in light of the case of a patient whose management was modified after identifying this anatomical variation.

Transvenous embolization of a dural carotid-cavernous fistula through the contralateral superior petrosal sinus

We report a patient with progressive ophthalmological problems related to a dural carotid-cavernous fistula who was successfully treated endovascularly. Cavernous sinus catheterization was achieved through the contralateral superior petrosal sinus, permitting occlusion of the fistula without complications.

[Interdisciplinary treatment of carotid cavernous fistulas via the superior ophthalmic vein]

BACKGROUND

The endovascular occlusion of symptomatic carotid cavernous fistulae (CCF) via the transfemoral approach is safe and effective. Due to anatomical variations or after unsuccessful transarterial therapy, a direct surgical approach to the superior ophthalmic vein (SOV) may be necessary.

CASE REPORTS

In two patients with acute ophthalmologic symptoms coil occlusion of the CCF was performed after palpebral incision and cannulation of the SOV.

RESULTS

In both patients preparation of the SOV was performed successfully and without complications. After coil embolization of the CCF both patients had complete resolution of symptoms within several weeks. During a follow-up of 12 months there were no recurrences, but both patients exhibited moderate blepharoptosis.

CONCLUSION

Embolization of CCF via a surgically created approach is an effective procedure in selected cases when standard interventional treatment is not possible.

Neurovascular rescue

Neurovascular complications of carotid artery stenting (CAS) include intracranial embolism and hemorrhage, carotid dissection, in-stent thrombosis and vasospasm. Management of these crises requires knowledge of the intracranial vascular anatomy and collateral circulation, correct identification of the complication and its clinical implications, and a response plan that is appropriate to the complication and to the skill set of the operator. In this chapter the authors discuss techniques for the avoidance and management of CAS procedural complications.

Treatment of Intracranial Dural Arteriovenous Fistulas: Current Strategies Based on Location and Hemodynamics, and Alternative Techniques of Transcatheter Embolization

Intracranial dural arteriovenous fistulas (AVFs) can occur anywhere within the dura mater. Patients may be clinically asymptomatic or may experience symptoms ranging from mild symptoms to fatal hemorrhage, depending on the location (eg, cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal sinus, anterior fossa) and venous drainage pattern of the AVF. In the past, dural AVFs have been treated with a variety of approaches, including surgical resection, venous clipping, transcatheter embolization, radiation therapy, or a combination of these treatments. Recent developments in catheter intervention now allow most patients to be cured with transcatheter embolization, although stereotactic radiation therapy is demonstrating good results in an increasing number of cases and surgery is still the preferred option in some cases. Familiarity with drainage patterns, the risk of aggressive symptoms, recent technical advances, and current treatment strategies is essential for the treatment of intracranial dural AVFs.

Cavernous sinus dural fistula treated by transvenous facial vein approach

SUMMARY

We report on the endovascular treatment of the spontaneous indirect dural carotid cavernous sinus type D fistula in a 60-year-old woman, in whom ipsilateral facial, angular and superior ophthalmic veins catheterization was performed to get access to the fistula site for embolization treatment. Approach via the facial vein is helpful after inferior petrosal sinus treatment failure. Although this technique requires caution in the angular vein region it allows a safe and effective treatment of these lesions. 3D rotational digital angiography can obtain more information of the angioarchitecture of the cavernous plexus and venous outflow for the catheter navigation.

Treatment of Trapped CCF by Direct Puncture of the Cavernous Sinus by Infraocular Trans-SOF Approach. Case Report and Anatomical Basis

SUMMARY

We present a case of recurrent carotid-cavernous fistula after prior ipsilateral carotid artery ligation. Due to lack of endovascular access, embolization was performed by direct puncture of the cavernous sinus via a transorbital approach. Operative technique and an anatomical basis for treatment are described.

Embolisation of both fistulae through the same carotid artery tear in a patient with bilateral traumatic caroticocavernous fistulae

Endovascular treatment of traumatic caroticocavernous fistulae (CCF) may present technical difficulties with specific angiographic dilemmas. We report endovascular techniques used in a patient with bilateral post-traumatic CCF, high-flow on one side, and slow-flow on the other. Complete closure of both was achieved through the same carotid artery tear. To our knowledge, transarterial venous coil embolisation of a low-flow fistula through a contralateral carotid artery tear, with transarterial detachable balloon embolisation of the ipsilateral high-flow fistula has not been described previously.

Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches

There are multiple transvenous approaches for treatment of cavernous dural arteriovenous fistulae (DAVF). The choice of a specific route depends on the compartment of the cavernous sinus involved in the fistula and its venous drainage. We used two different facial vein approaches to treat patients with cavernous DAVF draining directly into the anterior compartment of the cavernous sinus and thence to the superior ophthalmic vein. Other transvenous routes to the sinus were not apparent. Embolization was targeted to the involved compartment with preservation of those not embolized. No major post-procedure ophthalmic venous engorgement occurred. We believe that ideal treatment of cavernous DAVF is targeted transvenous coil deposition, which necessitates detailed knowledge of the anatomy of the facial veins and cavernous sinus compartments.

Transvenous treatment of carotid cavernous and dural arteriovenous fistulae: results for 31 patients and review of the literature

OBJECTIVE

To evaluate findings for patients with carotid cavernous fistulae or dural arteriovenous fistulae (AVFs) who underwent transvenous embolization via different transvenous approaches.

METHODS

Retrospective analysis of data for 31 patients (age range, 17-81 yr; mean age, 59.3 yr) with carotid cavernous fistulae (n = 6) or dural AVFs (cavernous sinus [CS], n = 11; transverse/sigmoid sinus, n = 14) was performed. The AVFs were treated with coils via different transvenous approaches, in 56 procedures. Doppler ultrasonography and time-resolved, two-dimensional, magnetic resonance projection angiography were performed to confirm the treatment. The mean clinical follow-up period was 32.5 months.

RESULTS

A total of 34 transvenous procedures were performed for 17 AVFs of the CS. Eleven patients with AVFs of the CS (63%) were cured with respect to clinical symptoms, and six patients experienced improvement (37%). The approach via the internal jugular vein and inferior petrosal sinus (n = 15) was possible in 60% of cases, with complete occlusion of the fistula in 78% of cases. With the approach via the facial vein (n = 8), there was a 50% success rate. The superior ophthalmic vein approach (n = 5) was associated with a high rate of technical success (100%), with a rate of complete fistula occlusion of 80%. We encountered complications, with transient morbidity, in four cases (23.5%). For 14 dural AVFs of the transverse/sigmoid sinus, 22 transvenous procedures were performed; 12 patients were cured (85.7%) and 2 experienced improvement (14.3%). The technical success rate was 86%, with complete occlusion in 42% of cases. Minor complications occurred in six cases (42.9%) but did not lead to permanent morbidity.

CONCLUSION

Transvenous treatment of CS and transverse/sigmoid sinus AVFs can be effective if all transvenous approaches, including combined surgical/endovascular approaches, are considered.

Surgical transvenous embolization of a carotid-cavernous dural fistula with cortical drainage via a petrosal vein: two technical case reports

OBJECTIVE AND IMPORTANCE

We present two interesting cases involving carotid-cavernous dural fistulae draining only or predominantly into the petrosal vein after previous incomplete, complicated, endovascular treatments. Transvenous embolization with Guglielmi detachable coils, via the petrosal vein, during surgical exposure completely obliterated the fistulae.

CLINICAL PRESENTATION

A 64-year-old man manifesting left ocular symptoms after incomplete embolization of a left carotid-cavernous dural fistula and a 56-year-old woman manifesting left hemiparesis after complicated embolization of a right carotid-cavernous dural fistula were referred to our hospital. A percutaneous transvenous approach was attempted in both cases, but the catheter could not reach the fistula site. A combined open surgical and endovascular approach was then used.

INTERVENTION

The hemispheric branch of the petrosal vein was exposed via a retromastoid craniectomy. The catheter was then directly introduced into the hemispheric branch, followed by navigation into the fistula site. The fistula was completely embolized with Guglielmi detachable coils.

CONCLUSION

The technique of surgical transvenous embolization via a petrosal vein is a valuable alternative for the treatment of carotid-cavernous dural fistulae that drain only or predominantly into the petrosal vein, when the percutaneous transvenous route is not accessible.

Transfemoral superior ophthalmic vein approach via the facial vein for the treatment of carotid-cavernous fistulas--two case reports

Two elderly female patients with carotid-cavernous fistulas (CCFs) were treated by transvenous embolization through a transfemoral superior ophthalmic vein approach via the facial vein. Complete occlusion of CCFs was not achieved with this technique exclusively, but the technique was effective in these cases. This technique provides an alternative to other transvenous approaches for the treatment of CCFs.

Dural Fistulas

The treatment of dural fistulas is varied and complex. Treatment decisions require consideration of the nature of the symptoms, the location of the lesion, the complexity of the angioarchitecture, and the risk of progression. Standard treatment modalities include compression therapy, endovascular embolization, neurosurgery, and radiosurgery. Complex lesions will often require multiple different interventions. Because dural fistulas may present with a variety of neurologic and ophthalmologic problems, a team of neurologists, neuro-ophthalmologists, neuroradiologists, and neurosurgeons should develop a comprehensive treatment plan.

Puncture of the superficial sylvian vein for embolisation of cavernous dural arteriovenous fistula

SUMMARY

Dural arteriovenous fistulas (DAVF's) of the cavernous sinus are curable by endovascular means in the vast majority of cases. Both transarterial and transvenous approaches by femoral route can be used for closure. In rare cases with unsuitable anatomy or angioarchitecture, an endovascular approach is proposed by open surgical exposure of a major venous outflow, e.g. the superior ophthalmic vein. We report on a case of unsuccessful attempts at transarterial and transvenous catheter navigation through traditional endovascular routes, where surgical exposure of the major cortical venous drainage was necessary. A direct puncture of the sylvian vein allowed placement of a microcatheter in the cavernous sinus and occlusion of the fistula by coils.

Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature

BACKGROUND

The aim of this study is to describe the technique and results of the endovascular approach through the thrombosed inferior petrosal sinus (IPS) for occlusion of dural cavernous sinus fistulas (DCSFs).

METHODS

In four patients presenting with clinically symptomatic DCSFs, the angiogram did not show opacification of the IPS, indicating that it neither drained the arteriovenous fistula nor the cerebral venous outflow. A large volume biplane phlebogram of the jugular bulb was obtained to identify a thrombosed remnant of the IPS. We were able to navigate small hydrophilic catheters and microguide wires through the thrombosed IPS into the ipsi- or contralateral CS. After reaching the fistula site the CS was packed with detachable platinum coils.

RESULTS

We were able to reach the fistula site and to achieve a dense packing of coils within the arteriovenous shunting zone in all of the patients. The final angiogram showed subtotal or complete occlusion of the arteriovenous fistula. All four patients recovered completely and showed disappearance of the fistula on follow-up arteriograms. One patient developed a transient sixth nerve palsy. No complications related to the approach were observed.

CONCLUSIONS

For endovascular treatment, transvenous occlusion of DCSFs via the IPS is a feasible approach, even when this sinus is partially or completely thrombosed. Gentle handling of recently available, improved hydrophilic microguide wires and microcatheters allows effective and safe catheter navigation into the CS. A phlebogram of the jugular bulb is very useful for identification of a thrombosed IPS.

Percutaneous transfemoral embolization of an indirect carotid-cavernous fistula with cortical venous access to the cavernous sinus. Case report

The authors present the case of a 61-year-old man with an indirect carotid-cavernous fistula (CCF). Many now advocate a primary transvenous approach to deal with such lesions, with packing and thrombosis of the cavernous sinus leading to fistula obliteration. Transvenous access to the cavernous sinus via the inferior petrosal sinus is the usual route of access; both surgical and transfemoral superior ophthalmic vein approaches are also well described. In the case presented, the anatomy of the CCF was unfavorable for these approaches and its dominant venous egress was via a single enlarged arterialized cortical vein. The cavernous sinus was accessed with a transfemoral retrograde approach to the cortical draining vein. Successful CCF embolization was documented radiographically and clinically. To the authors' knowledge, this procedure has not been previously described in the English literature.