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

Transarterial embolization in non-cavernous and cavernous sinus dural arteriovenous fistulas: A systematic review and meta-analysis of proportions

BACKGROUND

Transarterial embolization (TAE) is pivotal in managing non-cavernous and cavernous sinus dural arteriovenous fistulas (CSDAVFs).

METHODS

Systematic searches were conducted across ScienceDirect, Medline, and Cochrane databases for longitudinal studies on TAE outcomes in non-CSDAVFs and CSDAVFs. Post-procedural outcomes, including complete, incomplete, and failed AVFs obliteration, and end-study outcomes were analyzed.

RESULTS

Our meta-analysis involved 27 studies with 643 patients and 736 fistulas. Symptoms in both groups included tinnitus (29.74 %), ocular/visual symptoms (29.12 %), hemorrhage (19.42 %), and headache (19.11 %). Feeding arteries mainly originated from the meningeal arteries (49.16 %). In non-CSDAVFs cases, fistula locations were within sinus complexes (69.23 %) and specific dural areas (28.31 %). Complete AVFs obliteration was 81 % (95 %CI: 70 % - 90 %), slightly higher in non-CSDAVFs (82 %, 95 % CI: 69 % - 92 %) than CSDAVFs (79 %, 95 %CI: 58 % - 95 %). Incomplete obliteration occurred in 14 % (95 %CI: 5 % - 39 %), with rates of 11 % (95 %CI: 2 % - 26 %) in non-CSDAVFs and 19 % (95 % CI: 5 % - 39 %) in CSDAVFs. Failed obliteration was rare (1 %, 95 %CI: 0 % - 3 %), with similar rates in both groups. At end-study follow-up, resolution of AVFs was achieved in 97 % of cases (95 %CI: 92 % - 100 %). However, complications occurred in 17 % of cases (95 %CI: 10 % - 25 %), with a higher incidence in CSDAVFs (22 %, 95 %CI: 9 % - 37 %) compared to non-CSDAVFs (13 %, 95 %CI: 6 % - 23 %).

CONCLUSIONS

TAE with embolic agents demonstrates favorable outcomes in non-CSDAVFs and CSDAVFs, with high rates of AVFs obliteration and resolution. Complications, particularly in CSDAVFs, warrant careful consideration in treatment decisions.

Facilitated Retrograde Access via the Facial Vein for Transvenous Embolization of the Cavernous Sinus Dural Arteriovenous Fistula with Isolated Ophthalmic Venous Drainage

Management of cavernous sinus dural arteriovenous fistula (CSDAVF) continues to present significant challenges, particularly when the inferior petrosal sinus is thrombosed, collapsed, or angiographically invisible. In this study, we introduce facilitated retrograde access via the facial vein, which is employed in the transvenous embolization of CSDAVF with isolated superior ophthalmic venous drainage. We also present illustrative cases and technical points.

Angiographic evaluation of the distance from the top of the jugular bulb to the inferior petrosal sinus-internal jugular vein junction: simple classification and identification method for the orifice of the non-visualized inferior petrosal sinus during neuroendovascular surgery

BACKGROUND

The inferior petrosal sinus (IPS) is the transvenous access route for neurointerventional surgery that is occasionally undetectable on digital subtraction angiography (DSA) because of blockage by a clot or collapse. This study was aimed at analyzing the distance from the jugular bulb (JB) to the IPS-internal jugular vein (IJV) junction and proposing a new anatomical classification system for the IPS-IJV junction to identify the non-visualized IPS orifice.

METHODS

DSA of 708 IPSs of 375 consecutive patients were retrospectively investigated to calculate the distance from the top of the JB to the IPS-IJV junction, and a simple classification system based on this distance was proposed.

RESULTS

The median distance from the top of the JB to the IPS-IJV junction was 20.8 ± 14.7 mm. Based on the lower (10.9 mm) and upper (31.1 mm) quartiles, IPS-IJV junction variants were: type I, 0-10 mm (22.3%); type II, 11-30 mm (45.8%); type III, > 31 mm (23.9%); and type IV, no connection to the IJV (8.0%). Bilateral distances showed a positive interrelationship, with a correlation coefficient of 0.86. The bilateral symmetry type (visualized IPSs bilaterally) according to our classification occurred in 267 of 300 (89.0%) patients.

CONCLUSIONS

In this study, the IPS-IJV junction was located far from the JB (types II and III), with a higher probability (69.6%). This distance and the four-type classification demonstrated high degrees of homology with the contralateral side. These results would be useful for identifying the non-visualized IPS orifice.

Superior ophthalmic approach in carotid-cavernous fistula: current concepts in indications, surgical techniques, and case reviews

Carotid-cavernous fistulas, characterized by abnormal arteriovenous communication within the cavernous sinus (CS), can be classified as direct or indirect. Direct fistulas are defined as a direct connection between the internal carotid artery (ICA) and CS, whereas indirect fistulas result from an abnormal connection between the CS and dural arterial branches. The first-line treatment for both types of fistulas is endovascular intervention, most commonly accomplished through the transarterial and transvenous approaches of the conventional pathway, including the ICA, inferior and superior petrosal sinuses, or basilar plexus. Nonetheless, a retrograde approach through the superior ophthalmic vein may be necessary for individuals in whom conventional endovascular treatment fails. Herein, the current principles of surgical indication and technique are presented, along with case studies.

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.

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.

The Vascular Architecture of Cavernous Sinus Dural Arteriovenous Fistula and Its Impact on Endovascular Treatment Approach Selection and Outcome

BACKGROUND

A cavernous sinus (CS) dural arteriovenous fistula (DAVF) is a form of abnormal arteriovenous communication that can be treated with endovascular embolization. Establishing an optimal access route should be based on vascular architecture. We reviewed 64 patients with CS-DAVF who underwent endovascular embolization and report the endovascular treatment approach selection and outcome.

METHODS

Clinical data were obtained from 64 patients with CS-DAVF who had been surgically treated at the authors' hospital between 2009 and 2022. Patients' medical records, imaging data, and follow-up outcomes were retrospectively analyzed.

RESULTS

All 64 patients (15 male, 49 female; mean age, 50 years) underwent CS-DAVF embolization. The most common symptoms were exophthalmos (39.1%), chemosis (35.9%), and headache (28.1%). On digital subtraction angiography images, 34.4% of the DAVFs were unilateral, and 82.8% were fed by both the external carotid artery and internal carotid artery. Of the patients' inferior petrosal sinuses (IPSs), 54.7% were nonopacified. The most common intravascular approaches included trans-IPS (37.5%) and trans-artery (28.1%) approaches. More than half of the CS-DAVFs were embolized by both coils and Onyx (62.5%). A total of 85.9% of the fistulas were completely embolized, and the follow-up rate was 76.6%. The modified Rankin Scale score was 0.9 ± 1.0.

CONCLUSIONS

The vascular architecture of CS-DAVF is closely related to endovascular treatment approach selection and outcome. Combined with the modified IPS recanalization technique, the trans-IPS approach is the safest and most effective approach. Dual microcatheter and balloon assistance techniques ensure the safety and completeness of embolization.

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.

Operative Cannulation of the Superior Ophthalmic Vein for Embolization of Cavernous Sinus Dural Arteriovenous Fistulas: Surgical Techniques and Clinical Outcomes

BACKGROUND

Endovascular therapy is the first-line treatment for the cavernous sinus dural arteriovenous fistulas, particularly transvenous embolization. This study aimed to assess the trans-superior ophthalmic vein approach to embolization for its safety, efficacy, and viability as a first-line treatment in selected patients, with a description of the microsurgical and endovascular techniques.

METHODS

We retrospectively reviewed patients with cavernous sinus dural arteriovenous fistulas treated using the direct superior ophthalmic vein approach with n-butyl cyanoacrylate and coils as the main embolic materials from 2015 to 2021. The safety and efficacy of the treatment were evaluated based on ocular and neurological improvement, angiographic obliteration, and recurrence.

RESULTS

Of the 16 patients, all cases were diagnosed with cavernous sinus dural arteriovenous fistulas. The n-butyl cyanoacrylate was used as the sole embolic material in 12 cases, and coils were used in 4 cases. A direct superior ophthalmic vein approach was selected as the first option in 11 patients. All the patients achieved complete fistula obliteration and good recovery from ocular symptoms, accompanied by excellent cosmetic results. No recurrence was observed at a mean follow-up period of 26 months.

CONCLUSIONS

Microsurgical dissection for exposure and direct cannulation of the superior ophthalmic vein as a route for fistula obliteration delivers excellent clinical outcomes, with a low rate of complications. Not only is it safe and effective as an alternative approach but it can also serve as first-line treatment in selected patients.

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.

Simultaneous transarterial and transvenous contrast injection to reveal the fistulous point in carotid cavernous fistula: illustrative case

BACKGROUND

Access of the cavernous sinus (CS) via venous route from the inferior petrosal sinus (IPS) can sometimes be challenging during the treatment of carotid cavernous fistulas (CCF), largely because of anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection.

OBSERVATIONS

A 58-year-old male was transferred to our university hospital center after suspected diagnosis of CCF at another hospital by head computerized tomography-angiogram. His symptoms included three weeks of right eye pain that was later complicated by redness, diplopia, and blurry vision. In a diagnostic angiogram, separate contrast injections from the arterial side via internal carotid artery (ICA) and from the venous side via IPS did not reveal a connection point. Injecting contrast simultaneously from both arterial and venous ends resulted in visualization of a connection point allowing entry into the CS.

LESSONS

Technique of simultaneous contrast injection from ICA and internal jugular vein is comparatively simple and saves an operator prolonged time and complexity of approach. In our case, it revealed fistulous point allowing navigation and completing the coiling.

Transfemoral transvenous embolization through the vein of Trolard and superficial middle cerebral vein for cavernous sinus dural arteriovenous fistula with isolated cortical vein drainage: A case report and literature review

Background:

Endovascular treatment may be challenging for cavernous sinus dural arteriovenous fistulas (CSDAVFs) with prominent leptomeningeal drainage without other accessible routes. We report a case of CSDAVF with isolated cortical venous successfully drainage treated by percutaneous transvenous embolization through the vein of Trolard and superficial middle cerebral vein (SMCV). We also review the literature of CSDAVFs treated by transvenous embolization through SMCV with or without combined surgical approach.

Case Description:

A 46-year-old woman presented with ocular symptoms and delayed treatment was encountered due to the COVID-19 pandemic. Cerebral angiography showed a CSDAVF (Barrow type D, Borden II, and Cognard II a + b) with isolated cortical vein drainage. Percutaneous transvenous access to the fistula through the inferior petrosal sinus was attempted but failed. Transvenous embolization through the vein of Trolard and SMCV was further attempted, and satisfactory occlusion of the fistula was achieved with detachable coils. This access route was chosen because of the occlusion of other access routes and can obliterate the need for more invasive approach, that is, combined surgical and endovascular approach. Cerebral angiography obtained 6 months following the procedure, confirmed complete angiographic obliteration of the fistula. The patient made an uneventful recovery.

Conclusion:

To avoid invasive combined surgical and endovascular approach, transvenous embolization through the vein of Trolard and SMCV may be another accessible option for treating CSDAVF with isolated cortical venous drainage.

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.

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.

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.

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.