The cavernous sinus (CS) is one of the cranial dural venous sinuses. It differs from other dural sinuses due to its many afferent and efferent venous connections with adjacent structures. It is important to know well about its complex venous anatomy to conduct safe and effective endovascular interventions for the CS. Thus, we reviewed previous literatures concerning the morphological and functional venous anatomy and the embryology of the CS. The CS is a complex of venous channels from embryologically different origins. These venous channels have more or less retained their distinct original roles of venous drainage, even after alterations through the embryological developmental process, and can be categorized into three longitudinal venous axes based on their topological and functional features. Venous channels medial to the internal carotid artery “medial venous axis” carry venous drainage from the skull base, chondrocranium and the hypophysis, with no direct participation in cerebral drainage. Venous channels lateral to the cranial nerves “lateral venous axis” are exclusively for cerebral venous drainage. Venous channels between the internal carotid artery and cranial nerves “intermediate venous axis” contribute to all the venous drainage from adjacent structures, directly from the orbit and membranous skull, indirectly through medial and lateral venous axes from the chondrocranium, the hypophysis, and the brain. This concept of longitudinal venous axes in the CS may be useful during endovascular interventions for the CS considering our better understandings of its functions in venous drainage.
Carotid artery stenting (CAS) is an effective and less invasive alternative to carotid endarterectomy for internal carotid artery (ICA) stenosis, but the guiding catheter is often technically difficult to introduce into the common carotid artery (CCA) in patients with concomitant atherosclerotic disease in the peripheral vessels or aorta. A new pull-through technique between the superficial temporal artery (STA) and the brachial artery was used to deliver the guiding catheter into the CCA safely and steadily. An 83-year-old male presented with repeated transient left hemiparesis caused by severe stenosis of the origin of the right ICA. He also had severe systemic atherosclerotic disease with occlusion of the bilateral femoral arteries. The innominate artery branched at an acute angle from the aorta. Therefore, catheterization of the right CCA seemed to be impossible using a conventional approach. The guidewire introduced from the right STA was lassoed by a loop snare wire and pulled out of the left brachial artery, forming the pull-through system. The guiding catheter could be introduced into the CCA from the left brachial artery over this guidewire. Subsequently, successful stent placement was performed under the distal protection. This new technique may facilitate safe and stable CAS even in patients with a severely tortuous access route due to concomitant atherosclerotic disease.
IntroductionAlthough cavernous sinus (CS) dural arteriovenous fistulas (d-AVFs) are usually treated with transvenous embolization (TVE) via the inferior petrosal sinus (IPS), IPSs are sometimes thrombosed and angiographically invisible. In such cases, the first obstacle to TVE is detecting the entry to the IPS. We report a new technique for TVE via IPS using intravascular ultrasonography (IVUS).MethodsThree consecutive cases of CS d-AVF with ipsilateral or bilateral IPS occlusion were involved in this study. On TVE, the orifice of the IPS was investigated with IVUS placed in the jugular vein or jugular bulb.ResultsThis technique has been successfully adapted in all three cases. In two of these cases, IPS was well visualized with the help of IVUS, and TVE was successfully performed.ConclusionTo our knowledge, this is the first report to mention the usefulness of IVUS for detecting angiographically occult IPS.
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