Transorbital Approach for Endovascular Occlusion of Carotid-Cavernous Fistulas: Technical Note and Review of the Literature

Deep orbital puncture of the superior ophthalmic vein for embolization of indirect carotid-cavernous fistula: a case report, technical note and review of the current literature

PURPOSE

Carotid-cavernous fistulas (CCFs) are abnormal connections between the carotid artery and cavernous sinus, often causing ocular symptoms like chemosis, proptosis, and diplopia. Endovascular embolization is the preferred treatment, typically performed via the transfemoral transvenous route through the inferior petrosal sinus (IPS). However, we present a case and a systematic review of indirect CCF treated through deep orbital puncture of the superior ophthalmic vein (SOV) for embolization.

METHODS

We systematically revised the current literature on PubMed, Web of Science, and Embase, based on PRISMA guideline, concerning the deep orbital puncture of the SOV for embolization of indirect CCFs.

RESULTS

Our systematic review identified only eight eligible studies encompassing 17 patients, ranging in age from 34 to 82 years, underscoring the rarity of this specific approach. The most frequently used trajectory directed the needle along the floor of the orbit towards the superior orbital fissure or orbital apex, and a variety of embolization materials were used in the studies. While the technique has been mentioned in the literature, our analysis indicates that it remains infrequently reported, with many cases lacking consistent procedural details. Furthermore, we present a case of a 63-year-old woman with imaging suggesting a CCF and compatible symptoms. A transorbital puncture of the SOV was performed. Embolization was successfully achieved with ethylene vinyl alcohol copolymer. The follow-up confirmed the resolution of the CCF without new neurological deficits and no new symptoms.

CONCLUSION

This case highlights transorbital SOV puncture as a feasible and minimally invasive alternative for treating CCFs when conventional access is unsuccessful.

Connecting the dots: Linking superior ophthalmic vein and internal jugular vein diameter to carotid cavernous fistula type and location

Background

The specific objectives of this study are to identify the carotid cavernous fistula (CCF) type based on computerized tomography angiography (CTA) results, determine the cut-off diameter of the superior ophthalmic vein (SOV) and internal jugular vein (IJV) in CCF patients, and to evaluate the correlation between diameters of the right and left SOV and IJV with CCF type and location.

Methods

A retrospective analysis of data from 35 CCF patients at our institution was conducted between January 2016 and October 2022. The analysis separated the vascular diameters of the right and left SOV and IJV, which were compared to 35 non-CCF patients. The non-CCF group consisted of individuals who underwent CTA for conditions unrelated to vascular abnormalities.

Results

In 35 CCF patients, the dilatation of the left SOV was significantly correlated with direct CCF type with a cutoff of >0.5 cm and significantly associated with indirect CCF type with a cutoff of <0.5 cm (P = 0.017), while the right SOV was not significantly correlated (P = 0.187). There was no significant correlation between the right and left IJV with CCF type or location (right IJV, P = 0.996 and left IJV, P = 0.558). However, the analysis indicated that IJV size differences between CCF and non-CCF patients were significant.

Conclusion

Dilation of the left SOV correlates with both direct and indirect CCF types, while the right SOV and IJV (both sides) do not show a significant correlation with CCF type or location. This suggests that left SOV dilation may serve as an early indicator of CCF type, particularly in cases involving the left side.

Management of carotid cavernous fistulas: A single center experience

Purpose

Multimodal endovascular therapy (EVT) of carotid cavernous fistula (CCF) with different approaches and a variety of available embolization material enable high occlusion rates with good clinical and functional outcome but until now there is still little evidence available. This retrospective single-center study aims to evaluate EVT of CCF with different neuroendovascular techniques regarding occlusion rates, complications and outcomes.

Materials and methods

From 2001 to 2021 59 patients with CCF were treated at our tertiary university hospital. Patient records and all imaging data including angiograms were reviewed for demographic and epidemiological data, symptoms, fistula type, number of EVTs, complications of EVT, type of embolic materials, occlusion rates and recurrences.

Results

Etiology of the CCF were spontaneous (41/59, 69.5%) post-traumatic (13/59, 22%) and ruptured cavernous aneurysms (5/59, 8.5%). Endovascular therapy was completed in one session in 74.6% (44/59). Transvenous access was most frequent (55.9% 33/59) followed by transarterial catheterization in 33.9% (20/59) and a combination of both (6/59, 10.2%). Exclusively coils were used in 45.8% (27/59), a combination of ethylene vinyl alcohol (EVOH) copolymer (Onyx) and coils in 42.4% (25/59). Complete obliteration was achieved in 96.6% of patients (57/59) with an intraprocedural-related complication rate of 5.1% (3/59) and no mortality.

Conclusion

Endovascular therapy of CCF has been shown to be safe and effective with high cure rates and low rates of intraprocedural complications and morbidity even in complex scenarios.

Management of neurovascular emergencies with ophthalmic manifestations

Patients with neurovascular disorders sometimes approach the ophthalmologists with mild ophthalmic clinical features such as conjunctival congestion, slowly progressive proptosis, lateral rectus palsies and at other times with ophthalmic emergencies like sudden increase in proptosis, ophthalmoplegia, diplopia, and ptosis before the onset of neurological manifestations which may be life-threatening if not detected in time. The aim of this article is to focus on ophthalmic manifestations of neurovascular emergencies and role of ophthalmologists in its management. In this communication, to make the ophthalmologist aware of clinical presentations, the imaging modality of choice, diagnostic features, medical and interventional treatments. We have searched PubMed, Web of Science, Google Scholar and reviewed some of the commonly encountered neurovascular emergencies with ocular manifestations such as carotid-cavernous fistula, cerebral venous sinus thrombosis, cerebral artery aneurysms, arterio-venous malformations.

Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee

The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.

Carotid-cavernous fistula: current concepts in aetiology, investigation, and management

A carotid-cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus and may be classified as either direct or dural. Direct CCFs are characterized by a direct connection between the internal carotid artery (ICA) and the cavernous sinus, whereas dural CCFs result from an indirect connection involving cavernous arterial branches and the cavernous sinus. Direct CCFs frequently are traumatic in origin and also may be caused by rupture of an ICA aneurysm within the cavernous sinus, Ehlers-Danlos syndrome type IV, or iatrogenic intervention. Causes of dural CCFs include hypertension, fibromuscular dysplasia, Ehlers-Danlos type IV, and dissection of the ICA. Evaluation of a suspected CCF often involves non-invasive imaging techniques, including standard tonometry, pneumotonometry, ultrasound, computed tomographic scanning and angiography, and/or magnetic resonance imaging and angiography, but the gold standard for classification and diagnosis remains digital subtraction angiography. When a direct CCF is confirmed, first-line treatment is endovascular intervention, which may be accomplished using detachable balloons, coils, liquid embolic agents, or a combination of these tools. As dural CCFs often resolve spontaneously, low-risk cases may be managed conservatively. When invasive treatment is warranted, endovascular intervention or stereotactic radiosurgery may be performed. Modern endovascular techniques offer the ability to successfully treat CCFs with a low morbidity and virtually no mortality.