Onyx embolization of dural arteriovenous fistulas of the cavernous sinus through the superior pharyngeal branch of the ascending pharyngeal artery

Transcatheter arterial embolization for traumatic injury to the pharyngeal branch of the ascending pharyngeal artery: Two case reports

BACKGROUND

The ascending pharyngeal artery (APhA) comprises the pharyngeal trunk (PT) and neuromeningeal trunk. The PT feeds the nasopharynx and adjacent tissue, which potentially connects with the sphenopalatine artery (SPA), branched from the internal maxillary artery (IMA). Due to its location deep inside the body, the PT is rarely injured by trauma. Here, we present two cases that underwent transcatheter arterial embolization (TAE) of the PT of the APhA due to trauma and iatrogenic procedure.

CASE SUMMARY

Case 1 is a 49-year-old Japanese woman who underwent transoral endoscopy under sedation for a medical check-up. The nasal airway was inserted as glossoptosis occurred during sedation. Bleeding from the nasopharynx was observed during the endoscopic procedure. As the bleeding continued, the patient was referred to our hospital for further treatment. Contrast-enhanced computed tomography (CT) demonstrated extravasation in the nasopharynx originating from the right Rosenmuller fossa. TAE was performed and the extravasation disappeared after embolization. Case 2 is a 28-year-old Japanese woman who fell from the sixth floor of a building and was transported to our hospital. Contrast-enhanced CT demonstrated a complex facial fracture accompanying extravasation in the left pterygopalatine fossa to the nasopharynx. Angiography demonstrated an irregular third portion of the IMA. As angiography after TAE of the IMA demonstrated extravasation from the PT of the APhA, additional TAE to the artery was performed. The bleeding stopped after the procedure.

CONCLUSION

Radiologists should be aware that the PT of the APhA can be a bleeding source, which has a potential connection with the SPA.

Targeted Transvenous Embolization of Cavernous Sinus Dural Arteriovenous Fistula With Liquid Materials Using a Dual-Lumen Balloon Microcatheter

We describe a challenging transvenous embolization technique involving a dual-lumen balloon microcatheter (DLBM) and liquid materials for cavernous sinus dural arteriovenous fistula (CSDAVF).

DLBM contributed to identifying the shunt point and preventing liquid material leakage to normal venous drainage without treatment-related complications. In a transvenous embolization using liquid materials for CSDAVF complications such as cranial nerve palsy and embolic agent migration into the internal carotid artery due to numerous anastomoses must be considered. The use of angiography during DLBM inflation to characterize the shunt point and DLBM to prevent liquid material leakage to the normal venous drainage might decrease the mass effect due to liquid materials, thereby minimizing the causes of newly occurring cranial nerve palsy.

This technique may be helpful for the treatment of CSDAVF in practice, but there is generally a risk in using liquid materials in the cavernous sinus; therefore, further consideration is needed in the future.

Embolization of Dural Arteriovenous Fistula of the Cavernous Sinus Through Percutaneous Ultrasound-Guided Puncture of the Facial Vein

BACKGROUND

The goal of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus and consequently in the ophthalmic veins. The traditional approach in the treatment of these fistulae is transvenous endovascular occlusion of the cavernous sinus. Transvenous embolization has been proven to be safe and can provide complete and permanent occlusion of the fistula in a single session. The most commonly used venous pathway is the inferior petrosal sinus, but, if it is inaccessible, then, the superior ophthalmic vein is considered; nonetheless, it can require a surgical exposure. Other pathways include the transfemoral transfacial vein. An arterial approach is considered usually when venous approach pathways fail. Arterial occlusion of feeders supplying the fistula is associated with a greater risk of embolic complications.

CASE DESCRIPTION

We report a case of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein.

CONCLUSIONS

We propose an alternative pathway when the conventional transvenous approach through the inferior petrosal sinus is excluded. An ultrasound-guided facial vein approach can be considered as a direct and safe alternative to reach the cavernous sinus and obtain exclusion of the fistula.

The road less traveled: transarterial embolization of dural arteriovenous fistulas via the ascending pharyngeal artery

Background

With the introduction of Onyx, transarterial embolization has become the most common endovascular approach to treating dural arteriovenous fistulas (dAVFs), often via the middle meningeal or occipital arteries. The ascending pharyngeal artery (APA) is a less frequently explored transarterial route because of its small caliber, potential anastomoses to the internal carotid and vertebral arteries, and vital supply to lower cranial nerves.

Objective

To review our institutional experience and highlight the prevalence of APA supply to dAVFs and cases where it is a safe and effective pedicle for embolization.

Methods

We reviewed our endovascular database (January 1, 1996 to March 1, 2016) for cranial dAVFs, evaluating dAVF characteristics and embolization results for those treated transarterially via the APA.

Results

Of 267 endovascularly treated dAVFs, 68 had APA supply (25%). Of these 68 dAVFs, embolization was carried out via this pedicle in 8 (12%) and 7 were ultimately occluded. No complications, including post-treatment cranial neuropathies or radiographic evidence of non-target embolization, were found. For 5 dAVFs, the APA was selected as the initial pedicle for embolization (two marginal sinus, one distal sigmoid, one cavernous, one tentorial). In four of these five cases, dAVF occlusion was achieved via the initial APA feeding artery pedicle. In one case, near-complete, stagnant occlusion was achieved after APA embolization; complete occlusion was achieved after adjunctive embolization of a single additional middle meningeal artery pedicle. In three other cases of complex transverse/sigmoid dAVFs, the APA was used after multiple attempts via middle meningeal and occipital artery pedicles. Occlusion was not achieved transarterially; two of these three dAVFs were ultimately occluded transvenously.

Conclusions

In rare, select cases, the APA is an excellent route for transarterial embolization of cranial dAVFs.

Neuromeningeal access for transarterial intravenous carotid-cavernous fistula embolization

While numerous endovascular access routes have been described for carotid-cavernous fistula (CCF) treatment, transarterial embolization via the neuromeningeal trunk of the ascending pharyngeal artery is typically avoided due to the risk of cranial nerve palsy or non-target embolization via external-to-internal carotid anastamoses. We present the case of a dural CCF in which access to the venous side of the fistula was achieved via the neuromeningeal trunk and allowed for curative transarterial intravenous coil/liquid embolic embolization of the lesion. The utility of a transarterial intravenous approach in the face of venous sinus occlusion is highlighted. The neuromeningeal trunk should not be overlooked as a potential access route for transarterial intravenous CCF embolization in cases where traditional endovascular access is limited; this approach does not carry the same risks that are generally associated with pure transarterial embolization along this pathway.