Transvenous treatment of cavernous dural arteriovenous fistulae with onyx and coils

Transfemoral trans-facial vein-superior ophthalmic vein to embolize cavernous sinus dural arteriovenous fistulas

Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal communication between the CS and dural arteries from the internal carotid artery and external carotid artery. CS-DAVFs are not uncommon. The preferred treatment for most CS-DAVFs is transvenous embolization (TVE), which can achieve a high cure rate with few complications. The trans-inferior petrous sinus (IPS) route from the internal jugular vein to the CS is the favorite and most direct route to perform TVE in the great majority of CS-DAVFs. However, when the trans-IPS route fails and if the facial vein (FV) is patent and dilated, transfemoral trans-FV-superior ophthalmic vein (SOV) embolization of the CS-DAVF can be attempted. However, the transfemoral trans-FV-SOV route to embolize CS-DAVFs is often challenging, and there is insufficient knowledge about it. Therefore, an updated review of the transfemoral trans-FV-SOV route to embolize CS-DAVFs is necessary, and this review includes our experience. The images in this review are from our institute without the dispute of copyright. Issues regarding the transfemoral trans-FV-SOV route to embolize CS-DAV were discussed, including the FV anatomy and variation, various TVE routes to access CS-DAVF, the procedure of the transfemoral trans-FV-SOV route to embolize CS-DAVF, difficulty, and solution of the transfemoral trans-FV-SOV route to embolize CS-DAVF, and complications and prognosis of transfemoral trans-FV-SOV to embolize CS-DAVF. By reviewing the transfemoral trans-FV-SOV route to embolize CS-DAVFs, we found that this route provides a valuable alternative to the other transvenous routes. A good prognosis can be obtained with the transfemoral trans-FV-SOV route to embolize CS-DAVFs in select cases.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas. Institutional Series, Systematic Review and Meta-Analysis

Purpose

Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs.

Methods

PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center.

Results

A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5–96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82–12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001).

Conclusion

A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents.

The laterocavernous sinus system: venous inflows, venous outflows, and clinical significance

BACKGROUND

The laterocavernous sinus system is best defined as the entire territory served by the laterocavernous and the superior petrosal sinuses (SPS).

METHODS

The laterocavernous sinus is a small but important venous structure located between the two dural layers forming the lateral wall of the cavernous sinus and has been described as one of the principal drainage pathways of the deep and superficial middle cerebral veins.

RESULTS

Several disease processes in the head involve the laterocavernous sinus. To evaluate and treat these diseases it is necessary for neuroradiologists not only to know selective angiography and embolization techniques, but also the territory of the laterocavernous sinus and venous watershed between the deep and superficial venous systems.

CONCLUSIONS

In the present report the normal angiographic anatomy of the laterocavernous sinus system, its relationship with the deep and superficial venous systems, and its importance in clinical situations are outlined.

Transarterial and transvenous embolization for cavernous sinus dural arteriovenous fistulae

We report on the safety and efficacy of trans-arterial and transvenous Onyx embolization in the treatment of dural arteriovenous fistulae (DAVFs) of the cavernous sinus. We reviewed the findings from a retrospectively database for 22 patients with cavernous sinus DAVFs who were treated with either transarterial Onyx embolization alone (n = 8) or transarterial and transvenous Onyx embolization (n = 14) over a four year period. The mean follow-up period after endovascular treatment was 21.6 months (range 3-42 mths). Total number of embolizations was 27 for 22 patients. Two patients were treated transvenously after transarterial embolization. All 22 patients (100%) experienced improvement of their clinical symptoms. All 22 patients (100%) experienced total obliteration of their DAVFs, as documented by angiography performed at a mean follow-up of 5.8 months after the last treatment. No patient experienced a recurrence of symptoms after angiography showed DAVF obliteration. One patient exhibited temporary deterioration of ocular symptoms secondary to venous hypertension after near total obliteration; one had transient V cranial nerve deficit related to transarterial embolization, and two patients exhibited transient III and VI cranial nerve weakness related to transvenous embolization. Two patients experienced recurrent symptoms after incomplete transarterial embolization and underwent transvenous embolization at three and four months. Both patients achieved clinical and angiographic cures. Transarterial and transvenous embolization with Onyx, whenever possible, proved to be a safe and effective management for patients with cavernous sinus DAVFs.