Management of two cavernous sinus dural arteriovenous fistulae by direct microsurgical approach and catheterization of the superior ophthalmic vein

Cavernous sinus dural arteriovenous fistula embolized via a rare anastomosis between the facial vein and the superficial temporal vein

A cavernous sinus dural arteriovenous fistula (CSdAVF) is an abnormal communication between the dural branches of the internal and external carotid arteries and the cavernous sinus. Transvenous embolization is the first choice to resolve CSdAVFs, and various venous access routes have been reported. However, transvenous embolization of a CSdAVF through a rare venous anastomosis between the facial and superficial temporal veins using a quadruple coaxial catheter system is scarce in the literature. A 30-year-old woman presented with a typical triad of CSdAVF that was supplied by the inferolateral and meningohypophyseal trunks and several dural branches of the external carotid artery. CSdAVF was solely draining through the right superior ophthalmic vein to the bilateral facial veins. The right facial vein had a rare anastomosis, with the superficial temporal vein terminating in the external jugular vein. Transvenous targeted embolization of CSdAVF was performed through the right superior ophthalmic vein. The rare anastomosis between the right superficial temporal vein and the right facial vein was used as the access route for CSdAVF. The quadruple coaxial catheter system was effective in overcoming the long and tortuous access route and stabilizing the movement of the microcatheter for target embolization. CSdAVF was successfully embolized with microcoils. This is the first report of a CSdAVF embolized via a rare anastomosis between the facial vein and the superficial temporal vein. A quadruple coaxial catheter system can overcome this unusual access route.

Percutaneous Ultrasound-Guided Access to the Superior Ophthalmic Vein for Embolization of a Cavernous Sinus Dural Arteriovenous Fistula

The treatment of symptomatic cavernous sinus dural arteriovenous fistula, an unusually occluded cavernous sinus, is by a transvenous approach through the inferior petrosal sinus and superior ophthalmic vein. If these two modes of conventional transvenous access are not possible, surgical exposure and/or direct puncture access to the superior ophthalmic vein or cavernous sinus have been previously described. In a patient with progressive ophthalmological problems, the goal of treatment is to not only cure the ophthalmic symptoms but also to conserve or improve visual acuity, so treatment is needed as soon as possible. We report a 68-year-old woman suffering a Barrow type D cavernous sinus dural arteriovenous fistula. In this case, inadequate, inferior petrosal sinus embolization and lack of access for superior ophthalmic vein via a facial vein preceded percutaneous puncture under sonographic guidance of the superior ophthalmic vein. This permitted venous occlusion without complications and symptom-free for 11 months.

Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

A cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication involving the dura mater within or near the CS wall. The dural arteries from the internal carotid artery and external carotid artery supply the CS-DAVF, and the superior ophthalmic vein (SOV) and inferior petrous sinus (IPS) are frequent venous drainers. In CS-DAVF cases, high-risk lesions require treatment. Endovascular treatment (EVT) has been the first-line option for CS-DAVFs. To our knowledge, a review of the EVT of CS-DAVFs is lacking. Therefore, in this paper, we review the available literature on this issue. In addition, some illustrative cases are also provided to more concisely expound the EVT of CS-DAVFs. According to the recent literature, transvenous embolization via the IPS is considered the most effective method for EVT of CS-DAVFs. In addition, the transorbital approach is another reasonable choice. Other venous approaches can also be tried. Because of the low cure rate, transarterial embolization for CS-DAVFs is limited to only highly selected patients. In the EVT of CS-DAVFs, various agents have been used, including coil, Onyx, and n-butyl cyanoacrylate, with coil being the preferred one. In addition, when EVT cannot obliterate the CS-DAVF, stereotactic radiotherapy may be considered. In general, despite various complications, EVT is a feasible and effective method to manage CS-DAVFs by way of various access routes and can yield a good prognosis.