Transvenous microguidewire looping technique for breach of ipsilateral inferior petrosal sinus occlusions en route to cavernous sinus dural arteriovenous fistulas

Image fusion technique using flat panel detector rotational angiography for transvenous embolization of intracranial dural arteriovenous fistula

Precise evaluation of the feeders, fistulous points, and draining veins plays a key role for successful embolization of intracranial dural arteriovenous fistulas (DAVF). Digital subtraction angiography (DSA) is a gold standard diagnostic tool to assess the exact angioarchitecture of DAVFs. With the advent of new image postprocessing techniques, we lately have been able to apply image fusion techniques with two different image sets obtained with flat panel detector rotational angiography. This new technique can provide additional and better pretherapeutic information of DAVFs over the conventional 2D and 3D angiographies. In addition, it can be used during the endovascular treatment to help the accurate and precise navigation of the microcatheter and microguidwire inside the vessels and identify the proper location of microcatheter in the targeted shunting pouch. In this study, we briefly review the process of an image fusion technique and introduce our clinical application for treating DAVFs, especially focused on the transvenous embolization.

Endovascular treatment in bilateral cavernous sinus dural arteriovenous fistulas: a systematic review and meta-analysis

Few studies have discussed the disease nature and treatment outcomes for bilateral cavernous sinus dural arteriovenous fistula (CSDAVF). This study aimed to investigate the clinical features and treatment outcomes of bilateral CSDAVF. Embase, Medline, and Cochrane library were searched for studies that specified the outcomes of bilateral CSDAVF from inception to April 2022. The classification, clinical presentation, angiographic feature, surgical approach, and treatment outcomes were collected. Meta-analysis was performed using the random effects model. Eight studies reporting 97 patients were included. The clinical presentation was mainly orbital (n = 80), cavernous (n = 52) and cerebral (n = 5) symptoms. The most approached surgical route was inferior petrosal sinus (n = 80), followed by superior orbital vein (n = 10), and alternative approach (n = 7). Clinical symptoms of 88% of the patients (95% CI 80-93%, I² = 0%) were cured, and 82% (95% CI 70-90%, I² = 7%) had angiographic complete obliteration of fistulas during follow up. The overall complication rate was 18% (95% CI 11-27%, I² = 0%). Therefore, endovascular treatment is an effective treatment for bilateral CSDAVF regarding clinical or angiographic outcomes. However, detailed evaluation of preoperative images and comprehensive surgical planning of the approach route are mandatory owing to complexity of the lesions.

Cavernous sinus dural arteriovenous fistula treated with transvenous embolization through facial vein: A case report

BACKGROUND

Although the inferior petrosal sinus (IPS) is the most common approach route for transvenous embolization (TVE) of cavernous sinus dural arteriovenous fistulas (CSDAVFs), other routes should be chosen in cases which the IPS is occluded. We report a case in which the superior ophthalmic vein (SOV) approach through the facial vein (FV) was the first choice to achieve radical cure of a hemorrhage-onset CSDAVF.

CASE DESCRIPTION

An 81-year-old female presented with a history of transarterial embolization (TAE) and TVE for the left CSDAVF 27 years ago. She was transported to us with a chief complaint of consciousness disturbance, and head computed tomography (CT) showed subcortical hemorrhage in the right frontal lobe. Cerebral angiography revealed CSDAVF with draining into the right SOV and right superficial middle cerebral vein (SMCV). Angiography, computed tomography venography, and contrast-enhanced magnetic resonance imaging did not show IPS, but the outflow pathways to the SOV, FV, and internal jugular vein were confirmed, so an approach through the FV was selected.

CONCLUSION

The FV was selected through the right femoral vein and thanks to the distal access catheter (DAC) being guided to the SOV, the microcatheter could be easily guided to the SMCV through the cavernous sinus (CS). TVE was performed, complete occlusion was confirmed. When preoperative occlusion of the IPS was confirmed, the FV was useful for the first choice of route, and the use of DAC allowed us to complete the treatment accurately and quickly.

Transvenous embolization of the direct carotid-cavernous fistula via the pterygoid plexus: illustrative case

BACKGROUND

Endovascular treatment is the mainstay of treatment for carotid-cavernous fistulas, but endovascular approaches vary widely. The authors report a rare case of a direct carotid-cavernous fistula with cranial nerve symptoms caused by rupture of a giant aneurysm in which selective transvenous embolization via the pterygoid plexus was performed.

OBSERVATIONS

An 81-year-old man presented with headache and various progressive cranial nerve symptoms due to a direct carotid-cavernous fistula caused by a ruptured giant aneurysm. All the draining veins visualized on preoperative examination immediately before the treatment were occluded except for the pterygoid plexus. Therefore, the authors chose the dilated pterygoid plexus to approach the shunted pouch at the cavernous sinus and achieve shunt obliteration by selective embolization with coils and n-butyl cyanoacrylate.

LESSONS

Careful study of the three-dimensional rotational images in the preoperative examination is important when considering the various approaches to surgery. The pterygoid plexus can be an effective venous approach route to reach the cavernous sinus area.

Use of a Rigid-Tipped Microguidewire for the Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas with an Occluded Inferior Petrosal Sinus

Objective

Transvenous embolization (TVE) via an occluded inferior petrosal sinus (IPS) in a cavernous sinus dural arteriovenous fistula (CSDAVF) is challenging, often requiring navigation of a microcatheter through resistive obstacles between the occluded IPS and shunted pouch (SP), although the reopening technique was successfully performed. We report five cases of successful access to the cavernous sinus (CS) or SP using the rigid-tipped microguidewire such as chronic total occlusion (CTO) wire aiming to share our initial experience with this wire.

Methods

In this retrospective study, four patients with CSDAVF underwent five procedures using the CTO wire puncture during transfemoral transvenous coil embolization. Puncture success, shunt occlusion, and complications including any hemorrhage and cranial nerve palsy were evaluated.

Results

Despite successful access through the occluded IPS, further entry into the target area using neurointerventional devices was impossible due to a short-segment stricture before the CS (three cases) and a membranous barrier within the CS (two cases). However, puncturing these structures using the rigid-tipped microguidewire was successful in all cases. We could advance the microcatheter over the rigid-tipped microguidewire for the navigation to the SP and achieved complete occlusion of the SP without complications.

Conclusion

The use of the rigid-tipped microguidewire in the TVE via the occluded IPS of the CSDAVF would be feasible and safe.

Morphology of the groove of the inferior petrosal sinus: application to better understanding variations and surgery of the skull base

Although adequate venous drainage from the cranium is imperative for maintaining normal intracranial pressure, the bony anatomy surrounding the inferior petrosal sinus and the potential for a compressive canal or tunnel has, to our knowledge, not been previously investigated. One hundred adult human skulls (200 sides) were observed and documented for the presence or absence of an inferior petrosal groove or canal. Measurements were made and a classification developed to help better understand their anatomy and discuss it in future reports. We identified an inferior petrosal sinus groove (IPSG) in the majority of specimens. The IPSG began anteriorly where the apex of the petrous part of the temporal bone articulated with the sphenoid part of the clivus, traveled posteriorly, in a slight medial to lateral course, primarily just medial to the petro-occipital fissure, and ended at the anteromedial aspect of the jugular foramen. When the IPSGs were grouped into five types. In type I specimens, no IPSG was identified (10.0%), in type II specimens, a partial IPSG was identified (6.5%), in type III specimens, a complete IPSG (80.0%) was identified, in type IV specimens, a partial IPS tunnel was identified (2.5%), and in type V specimens, a complete tunnel (1.0%) was identified. An improved knowledge of the bony pathways that the intracranial dural venous sinuses take as they exit the cranium is clinically useful. Radiological interpretation of such bony landmarks might improve patient diagnoses and surgically, such anatomy could decrease patient morbidity during approaches to the posterior cranial fossa.

Transvenous Approaches to Embolization of Dural Arteriovenous Fistulae of the Cavernous Sinus

Dural arteriovenous fistulae of the cavernous sinus (CS) (previously often referred to indirect carotid cavernous fistulas) are rare vascular shunts involving meningeal branches and osseous branches of the external or internal carotid arteries and the CS. They typically present with ocular symptoms including pain, conjunctival injection, and proptosis. Left untreated there may be a risk of vision loss, and fistulas with cortical venous reflux through either the deep or superficial venous system may cause intracranial venous congestion or hemorrhage. Endovascular embolization is the standard treatment, and while transarterial routes may appear possible, transarterial embolization has considerable risks of ischemic complications. Conversely, transvenous routes achieve a high rate of fistula occlusion with a low risk of peri-procedural morbidity. Procedural success depends on identification of the venous outflows from the fistula and localization of the fistulous point, to select the best route of access to the CS, including the inferior petrosal sinus (IPS), intercavernous sinus, or superior ophthalmic vein, among others. Even if the IPS is not visualized, it may be possible to recanalize it to gain access to the CS. Embolization can be performed with a combination of coils, fibered coils, and liquid embolic agents, focusing on occlusion of the fistulous point or blocking high-risk venous outflow pathways. In this review we will highlight procedural pearls and potential pitfalls and our typical approach to these lesions based on illustrative examples.

Superficial middle temporal vein as a pivotal route to embolize dural carotid-cavernous fistulas

Dural carotid-cavernous fistulas (DCCF) are located in the cavernous sinus wall involving the arterial feeders from the external and internal carotid arteries. The venous route usually passes through the internal jugular vein and inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In cases of a thrombosed IPS, catheterization is not always possible because of the obstruction. Here, we report eight cases of DCCF treated with endovascular transvenous embolization via the superficial middle temporal vein (SMTV). A retrospective study involving eight patients with DCCF treated with transvenous embolization via SMTV was performed. In six patients, IPS was thrombosed. In one patient, IPS was patent, but we could not catheterize the internal jugular vein. In the other patient, because of the compartmentalization of the cavernous sinus, we could not access the anterior part of the cavernous sinus via IPS. Therefore, we performed the embolization via SMTV to occlude the shunts of the anterior part of the cavernous sinus. In all eight cases, navigating through the tortuous junction of the angular vein and superior ophthalmic vein (SOV) was possible. After transvenous catheterization of the cavernous sinus via SMTV, placement of coils resulted in complete occlusion of DCCF with clinical improvement in all eight patients. In the endovascular treatment of DCCF, the transfemoral approach via SMTV provides a pivotal route alternative to other transvenous routes. In patients with dilated SOV, catheterization of the cavernous sinus via SMTV is usually successful.

Efficiency of Endovascular Therapy for Bilateral Cavernous Sinus Dural Arteriovenous Fistula

BACKGROUND

The principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes.

METHODS

The data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ² test.

RESULTS

Bilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001).

CONCLUSIONS

Dangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.

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.

Intraprocedural Flat Panel Detector Rotational Angiography and an Image Fusion Technique for Delivery of a Microcatheter into the Targeted Shunt Pouch of a Dural Arteriovenous Fistula

The accurate and safe delivery of a microcatheter to a targeted shunt pouch is essential for successful transvenous embolization of intracranial dural arteriovenous fistulas. However, complex anatomy and variations in head and neck veins and occluded sinuses can hinder intraprocedural microcatheter delivery. In this study, we introduce an intraprocedural flat panel detector rotational angiography and image fusion technique to aid precise navigation inside the veins and proper placement of the microcatheter in the targeted shunt pouch.

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.

Cannulation of Occluded Inferior Petrosal Sinuses for the Transvenous Embolization of Cavernous Sinus Dural Arteriovenous Fistulas: Usefulness of a Frontier-Wire Probing Technique

BACKGROUND AND PURPOSE

Pursuing an alternative access route for transvenous embolization of cavernous sinus dural arteriovenous fistulas can be challenging in patients with an occluded inferior petrosal sinus. We found that cannulation of even a completely occluded inferior petrosal sinus is feasible, especially when using a standard hydrophilic-polymer-jacketed 0.035-inch guidewire as a frontier-wire for probing.

MATERIALS AND METHODS

From 2002 to 2017, the frontier-wire technique was tried in 52 patients with occluded inferior petrosal sinuses for transvenous embolization of cavernous sinus dural arteriovenous fistulas at our center. Technical success was defined as access into the affected cavernous sinus compartment with a microcatheter through the occluded inferior petrosal sinus and deployment of at least 1 coil. The complications and treatment outcomes were analyzed.

RESULTS

The frontier-wire technique was applied in 52 patients with 57 occluded inferior petrosal sinuses (52 ipsilateral and 5 contralateral inferior petrosal sinuses). Technical success rates were 80.8% (42/52) of patients and 73.7% (42/57) of inferior petrosal sinuses. Alternative transvenous routes were used in 3 patients, and transarterial access was used in 7 patients. Complete embolization of fistulas was achieved in 82.2% (37/45) of patients in the transvenous embolization group and in 14.3% (1/7) of patients in the transarterial group. No procedure-related morbidity or mortality was observed.

CONCLUSIONS

Transvenous embolization of cavernous sinus dural arteriovenous fistulas, even through a completely occluded inferior petrosal sinus, is feasible. The difficulty of passing the microcatheter can be minimized by prior probing of the occluded inferior petrosal sinus using a standard 0.035-inch guidewire; the trace of the guidewire on the roadmap image serves as a guide for microcatheter navigation through the inferior petrosal sinus on fluoroscopy.

Transarterial Embolization of Cavernous Sinus Dural Arteriovenous Fistulas with Ipsilateral Inferior Petrosal Sinus Occlusion via the Ascending Pharyngeal Artery

BACKGROUND

Although the ipsilateral inferior petrosal sinus (IPS) is preferred for treatment of cavernous sinus dural arteriovenous fistulas (CS-dAVFs), this method is problematic if ipsilateral IPS is occluded. We describe our experience in treating CS-dAVFs with ipsilateral IPS occlusion via the ascending pharyngeal artery (APA).

METHODS

Between January 2013 and June 2017, of 36 CS-dAVFs, 23 with ipsilateral IPS occlusion were identified. Clinical charts, procedural data, angiographic results, and follow-up data were retrospectively reviewed.

RESULTS

Of 23 CS-dAVFs, 16 displayed a single or dominant feeding APA on cerebral angiography, of which 13 were treated via the APA initially. Fistulas were occluded successfully through the neuromeningeal trunk of the APA in 7 cases and through the superior pharyngeal branch of the APA in 3 cases. Glue leakage occurred in 2 cases via the superior pharyngeal branch of the APA, and superior pharyngeal branch rupture occurred during superselection of the microguidewire in 1 patient, who was treated by opening the occluded ipsilateral IPS. During the follow-up period, 12 of 13 patients had complete occlusion, and no cranial nerve palsy occurred.

CONCLUSIONS

CS-dAVF with ipsilateral IPS occlusion can be treated via various methods. Embolization through the APA as an initial access is a reasonable choice.

Endovascular Treatment of Bilateral Cavernous Sinus Dural Arteriovenous Fistula: Therapeutic Strategy and Follow-Up Outcomes

Objective

Bilateral cavernous sinus dural arteriovenous fistula (CSdAVF) is very rare, even in Asian countries. The research intended to present clinical and radiologic outcomes of treating such fistulas through endovascular embolization.

Materials and Methods

Data was obtained from 220 consecutive patients, with CSdAVF, who were treated from January 2004 to December 2015. Bilateral CSdAVF was identified in 17 patients (7.7%). The clinical and radiologic outcomes of the fistulas were assessed with an emphasis on the technical aspects of treatment.

Results

At the time of treatment, 7 and 10 patients presented with bilateral and unilateral symptoms, respectively. In the former cases, 4 patients had progressed from unilateral to bilateral symptoms. Bilateral fistulas were treated with a single-stage transvenous embolization (TVE) in 15 patients, via bilateral inferior petrosal sinuses (IPS) (n = 9) and unilateral IPS (n = 6). In the other 2 patients with one-sided dominance of shunting, only dominant fistula was treated. Two untreated lesions were found on follow-up to have spontaneously resolved after treatment of the dominant contralateral fistula. Of the 34 CSdAVF lesions, complete occlusion was achieved in 32 lesions after TVE. Seven patients (41.2%) developed worsening of cranial nerve palsy after TVE. During the follow-up period, 4 patients obtained complete recovery, whereas the other 3 remained with deficits.

Conclusion

With adjustments of endovascular procedures to accommodate distinct anatomical configurations, endovascular treatment for bilateral CSdAVF can achieve excellent angiographic occlusion results. However, aggravation of symptoms after TVE may occur frequently in bilateral CSdAVF. In the patients with one-sided dominance of shunt, treatment of only dominant fistula might be an alternative option.

Cavernous sinus dural arteriovenous fistula treated by facial vein direct puncture: Case report and review of the literature

Introduction In case of cavernous sinus dural arteriovenous fistula (CSDAVF), transvenous embolization (TVE) of the cavernous sinus (CS) via the inferior petrosal sinus (IPS) is generally performed. However, various approach routes have been reported when the accessibility of the IPS is challenging. We herein report a case of CSDAVF treated by TVE with direct puncture of the facial vein. Case report A 70-year-old woman who suffered from tinnitus, chemosis, diplopia and bruit was referred to our hospital. Digital subtraction angiography (DSA) demonstrated CSDAVF. We initially attempted to perform TVE via the IPS route; however, we could not guide a catheter to the CS because of an anatomical difficulty. Then, we performed percutaneous direct puncture of the dilated facial vein, and successfully treated the patient. Conclusion When navigating microcatheter to the CS is difficult because of an anatomical difficulty of the IPS, direct puncture of the facial vein is a feasible route.