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

Additional outlet occlusion as an important factor in avoiding retreatment after transvenous embolization for cavernous sinus dural arteriovenous fistulas

BACKGROUND

Transvenous embolization (TVE), such as selective shunt occlusion, is the first line treatment for cavernous sinus dural arteriovenous fistula (CSDAVF). Despite the favorable outcomes of TVE, some cases necessitating retreatment due to recurrence or incomplete occlusion persist. Given the physical, psychological, and financial burden of multiple treatments, understanding the predictive factors for recurrence, spontaneous occlusion, or retreatment is important. However, few reports have addressed these factors, complicating decision making regarding the need for retreatment. This study analyzed predictive factors for retreatment and spontaneous occlusion to offer new insights into CSDAVF management.

METHODS

This retrospective, observational study was conducted in two acute care hospitals. Patients aged 18-100 years undergoing endovascular treatment for CSDAVF from January 2011 to December 2022 were included.

RESULTS

Of 65 patients treated with TVE, 29 experienced immediate complete occlusion. Meanwhile, 22 of 36 patients with incomplete occlusion had spontaneous occlusion, and retreatment was performed in 20% of patients. Additional outlet occlusion was negatively associated with retreatment (P=0.046), and it tended to promote spontaneous occlusion (P=0.056). Favorable functional outcomes were observed in all patients, and approximately 94% of patients showed complete occlusion at the latest follow-up.

CONCLUSION

TVE is an effective treatment for CSDAVF. Outlet occlusion, when immediate complete occlusion is unattainable, is important to reduce retreatment and promote spontaneous occlusion. Substantially reducing shunt flow, carefully assessing dangerous drainage routes, and closely monitoring the residual shunt are crucial for preventing intracranial hemorrhage when outlet occlusion is performed.

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.

A Case of Direct Carotid-Cavernous Fistulae Successfully Treated by Bidirectional Double Catheter Technique: A Technical Note

Objective

Ruptured carotid-cavernous aneurysms (CCAs) are known to result in direct carotid-cavernous fistula (CCF). Although endovascular treatment is recognized as the first-line treatment for direct CCF, obliteration is sometimes difficult because of the high-flow shunt. In this report, we present a case of a direct CCF treated by the combination of transarterial and transvenous approaches.

Case Presentation

A 57-year-old woman presented with conjunctival chemosis, exophthalmos, and tinnitus. Ophthalmological examination revealed increased intraocular pressure. DSA demonstrated a direct CCF due to a right ruptured CCA with retrograde shunted flow through the superior ophthalmic vein (SOV), superficial middle cerebral vein, basal vein of Rosenthal, and middle temporal vein. Two microcatheters were guided into the shunt segment from the internal carotid artery and SOV. In addition, a balloon catheter was placed at the neck of the aneurysm to assist coiling. Coil embolization for the CCF was performed using two microcatheters in the opposite direction, which enabled compact and tight packing of the shunt segment with only six coils. The CCF was eliminated. Two-year-follow-up MRA revealed no recurrence.

Conclusion

The bidirectional double catheter technique is a useful approach to obliterate a shunt in a short segment with minimal coils.

Non-Sinus-Type Laterocavernous Sinus Dural Arteriovenous Fistula Treated by Transarterial Venous Coil Embolization: A Case Report

Objective

Laterocavernous sinus dural arteriovenous fistulas (DAVFs) are rare and not always accessible transvenously due to their angioarchitecture. We report a case of non-sinus-type laterocavernous sinus DAVF treated by endovascular transarterial venous coil embolization.

Case Presentation

A 78-year-old woman was admitted to our hospital with loss of consciousness, right hemiparesis, and motor aphasia. CT demonstrated intracerebral hematoma in the left frontal lobe and subarachnoid hemorrhage. On CTA and MRA, a DAVF was found in the left laterocavernous sinus region associated with the accessory meningeal artery (AMA) and draining directly into the superficial middle cerebral vein. The diagnosis was confirmed by DSA, which revealed a DAVF fed by the large and straight AMA and the internal carotid artery's meningohypophyseal trunk. Endovascular transarterial venous coil embolization was performed through the AMA. A microcatheter was advanced beyond the shunt point into the origin of the draining vein, and coils were placed in the venous and arterial sides of the fistula. The fistula was completely occluded, and 15-month follow-up angiography demonstrated stable obliteration of the fistula.

Conclusion

Transarterial venous coil embolization may be a treatment option for non-sinus-type laterocavernous sinus DAVF with a large fistula size and a large and straight feeding artery.