Contralateral transvenous approach and embolization with 360° guglielmi detachable coils for the treatment of cavernous sinus dural fistula

Unilateral Venous Approach to Contralateral or Bilateral Carotid Cavernous Shunts

BACKGROUND

Cavernous carotid fistulas (CCF) are anatomically complex vascular lesions. Treatment via the venous approach has been previously described and is highly dependent on the patency of the drainage pathways. The use of a unilateral approach to contralateral or bilateral shunts is technically challenging and not commonly described. We present our experience with the unilateral across-the-midline approach to both cavernous sinuses to treat shunts according to anatomic compartments to achieve anatomic cure.

METHODS

Patients included in this study presented with either bilateral or unilateral shunts with unilateral venous drainage. We used a transarterial guiding catheter for road mapping and control angiography. A venous triaxial system was used to achieve support for distal navigation across the midline via the coronary sinus to the contralateral cavernous sinus. Coils were favored for embolization, with occasional complementary liquid embolic material.

RESULTS

Five patients underwent complete occlusion in a single session. One patient required additional complementary transarterial embolization. Despite a successful unilateral approach to bilateral cavernous sinuses, 1 patient needed an additional ipsilateral transophthalmic venous approach to obliterate the anterior compartment of the cavernous sinus. No complications were encountered. Complete angiographic cure was observed in all patients by the end of the final procedures, with persistent occlusion in their follow-up imaging.

CONCLUSIONS

Careful inspection of the venous anatomy and fistulization sites is critical when treating unilateral or bilateral carotid cavernous shunts. The contralateral venous route can serve as a safe approach when visualized. Crossing the midline via the anterior or posterior coronary sinuses is feasible and efficacious.

Transvenous Embolization of Dural Arteriovenous Fistula of the Anterior Condylar Confluence via the Intercavernous Sinus Assisted by Bone Subtraction Computed Tomography Angiography

BACKGROUND

Dural arteriovenous fistulae (dAVFs) of the anatomically complex anterior condylar confluence (ACC) are often examined by computed tomography (CT) angiography and conventional angiography before treatment. Contrasted vessels often overlap with skull bones in enhanced CT scan and make it difficult to detect the shunt point of the dAVF. Bone subtraction CT angiography (BSCTA) can overcome this limitation and allow for superior imaging of dAVFs that may help to find an alternative access for catheterization.

CASE DESCRIPTION

An 80-year-old woman suffered from right ear tinnitus, headache, and an audible bruit. Preoperative imaging showed a dAVF of the ACC. It was fed by the bilateral ascending pharyngeal artery, drained to the internal jugular vein (IJV) via the inferior petrosal sinus, and had an intraosseous shunt pouch. We therefore performed transvenous embolization (TVE) via the intercavernous sinus because the angle between the anterior condylar vein and the IJV was too sharp to catheterize vessels through the ipsilateral IJV.

CONCLUSIONS

Understanding the inherently complex and individually unique venous anatomy of the ACC is crucial for treatment of dAVFs. BSCTA is an effective visualization technique for dAVFs of the ACC and allows for precise preoperative vascular structure evaluation. We suggest that in the case of the angle between the ACV and the IJV being too sharp to catheterize vessels through the ipsilateral IJV, TVE via the intercavernous sinus can be efficiently used.