Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas via Direct Transorbital Puncture Using Cone-Beam Computed Tomography Image Guidance: Report of 3 Cases

Direct puncture of the superior ophthalmic vein for carotid cavernous fistulas: a 21-year experience

BACKGROUND

Direct puncture of the superior ophthalmic vein (SOV) is an alternative approach to traversing the inferior petrosal sinus for embolization of carotid cavernous fistulas (CCFs).

OBJECTIVE

To analyze direct SOV puncture for the treatment of CCFs and review the literature.

METHODS

All patients at a single center, treated for a CCF with direct SOV cannulation between January 1, 2000, and December 31, 2020, were retrospectively analyzed. An additional review of the literature for all case series for direct puncture of the SOV for treatment of CCF was performed.

RESULTS

During the 21-year study period, direct cannulation of the SOV for treatment of a CCF was attempted for 19 patients, with the procedure aborted for one patient because of an inability to navigate the wire into the distal aspect of the cavernous sinus. In 18 patients with direct SOV CCF treatment, 1 experienced a minor complication with an asymptomatic postoperative hemorrhage. Angiographic cure and improvement of symptoms were achieved in 17 patients with a mean (SD) follow-up of 6 (5.2) months. In the review of the literature, an additional 45 patients were reported to have direct cannulation of the SOV for CCF treatment, with angiographic cure in 43 (96%) and decreased objective visual acuity in 1 (2%).

CONCLUSION

Direct SOV cannulation to treat CCFs is safe and effective. Although it is typically used after other endovascular approaches have failed, SOV access for CCF treatment may be warranted as a first-line treatment for select patients.

Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience

BACKGROUND

Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports.

OBJECTIVE

To report a multicenter experience assessing microsurgery safety/efficacy.

METHODS

Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021).

RESULTS

Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%.

CONCLUSION

Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.

Cone Beam CT to Guide Transorbital Treatment of a Cavernous Sinus Dural Arteriovenous Fistula in a Patient with Middle Meningeal Artery Origin of the Ophthalmic Artery

Transorbital puncture to embolize cavernous sinus (CS) dural arteriovenous fistulas (DAVF) is a useful strategy when conventional transvenous routes are inaccessible. We report a case of bilateral CS DAVF associated with bilateral middle meningeal artery (MMA) origin of ophthalmic arteries (OA) who had recently undergone transvenous coil embolization. She presented with persistent symptoms of conjunctival congestion and proptosis in the left eye. Angiogram revealed residual left CS DAVF with dilated SOV. Inferior petrosal sinus or facial vein access was not possible. Transorbital access of the SOV was planned. Cone-beam CT (CBCT) angiography was used to delineate the relationship between the variant OA and SOV and also to plan a safe trajectory. Using fluoroscopy guidance, the SOV was punctured and embolization was done using Onyx-18. CBCT is a valuable tool in planning and executing transorbital treatment of CS DAVF, especially in the setting of variant OA.

Middle temporal vein access for transvenous embolization of Cavernous sinus dural arteriovenous fistula: A case report and review of literature

Transvenous endovascular treatment is the first choice for treating most cavernous sinus dural arteriovenous fistulas (CDAVFs). Among several available venous routes, the inferior petrosal sinus is the most commonly used. We report a case of CDAVF treated with endovascular treatment via the middle temporal vein (MTV). A 65-year-old man presented with unilateral chemosis and exophthalmos for approximately two months. Digital subtraction angiography showed a right CDAVF with predominant venous drainage toward the right superior ophthalmic vein. The superior ophthalmic vein primarily drained into the dilated MTV. Both sides of the inferior petrosal sinus were occluded; therefore, transvenous embolization was performed via the MTV route. The fistula was completely obliterated. The patient's symptoms improved and the postoperative course was uneventful. The transfemoral approach via the MTV to treat CDAVF provides a crucial alternative when other venous routes are difficult or impossible to navigate with a catheter.

Embolization of Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF) via transvenous approaches: Practice, experience summary and literature review

OBJECTIVE

To evaluate the safety and efficacy of embolization via transvenous approaches in patients diagnosed with Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF). We also hope to further summarize our preliminary experiences with transvenous approaches.

MATERIAL AND METHODS

We retrospectively collected data from patients who were diagnosed with CSDAVF and were treated with embolization via transvenous approaches from June 2014 to November 2020 at Beijing Tiantan Hospital. We evaluated the safety and efficacy of this treatment using radiological results and clinical follow-up.

RESULTS

A total of 83 patients were included in this study. Complete occlusion was obtained in 76 (89.4%) patients. Sub-total occlusion was obtained in eight (9.4%) patients. Partial occlusion was obtained in one (1.2%) patient. There was no recurrence. Seventy-six patients (91.5%) were cured, and seven patients showed symptom improvement (8.5%). There were no cases of worsening symptoms following embolization, and only ten (12.0%) cases had mild complications.

CONCLUSION

There was a high occlusion rate and a low complication rate in our study. Thus, completing embolization of CSDAVF via transvenous approaches may be safe and effective. However, this operation is more difficult than those via transarterial approaches. Transvenous embolization should therefore be performed in an experienced medical center.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulae: Review of the Literature and Current Status

Cavernous sinus dural arteriovenous fistulae (CSdAVFs) are characterized by the shunts between dural arteries and dural veins surrounding the cavernous sinus (CS), causing ocular symptoms in addition to intracranial hemorrhage and infarction. As surgical access is difficult, endovascular treatment (EVT) has been considered and performed as the first-line therapy for decades. Although there have been recent advances in techniques and devices, transvenous embolization (TVE) with platinum coils remains the most common procedure. There are multiple access routes to the CS, such as the inferior petrosal sinus, superior ophthalmic vein (SOV), and intercavernous sinus from the contralateral CS. To extirpate the shunt, packing the entire sinus with coils is adopted, occasionally resulting in persistent cranial nerve palsy (CNP) due to compression of the coil mass. To avoid this complication, selective shunt occlusion (SSO), in which the coils are placed in the shunted pouch (SP) defined by the small restricted space where the arterial flow converges, is an effective and safe method. Transarterial embolization (TAE) is another option and use of liquid embolic materials, such as Onyx may be promising; however, the potential risk of ischemic nerve injury due to undesirable ante/retrograde influx of the liquid materials is of concern. In conclusion, EVT, especially TVE, is a safe and effective method for managing CSdAVFs. Understanding the angioanatomy consisting of the feeding artery, shunt point, and the drainage route, including the latent vessels, is essential for a good outcome.

Usefulness of an Electromagnetic Navigation System for Direct Percutaneous Puncture of the Superior Ophthalmic Vein

Objective

We report a case of dural arteriovenous fistula (dAVF) at the cavernous sinus treated by direct puncture of the superior ophthalmic vein (SOV) using an electromagnetic navigation system.

Case Presentation

The case involved a 70-year-old male patient who presented with mild chemosis, proptosis, and abducens palsy of the right eye. In this case, we used an electromagnetic navigation system for direct puncture of the SOV. Angiographic obliteration of the fistula was confirmed and the visual symptoms recovered well after surgery. There were no complications associated with direct puncture of the SOV using the electromagnetic navigation system.

Conclusion

Direct puncture of the SOV to obliterate a dAVF is a possible alternative choice of treatment when the usual transvenous access route fails. To reduce the risk of complications, an electromagnetic navigation system is useful.

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.