Blind endovascular catheterization and direct access of an occluded superior ophthalmic vein for treatment of carotid cavernous fistula

Abstract

SUMMARYWe describe a case of an elderly patient who presented with right-sided ophthalmoplegia, proptosis, chemosis, and increased intraocular pressure. An angiogram showed feeding vessels from the bilateral internal and external carotid arteries. Our initial attempt to blindly probe the inferior petrosal sinus was unsuccessful. This was followed by a right anterior orbitotomy exposing the superior ophthalmic vein which was directly cannulated with an 18 gauge angiocatheter. However, a proximal third of the superior ophthalmic vein within the orbit which was thrombosed was probed blindly. The thrombosed vein was cannulated with a microcatheter to obtain coil embolization of the carotid cavernous fistula. The implications of the procedure are discussed, given that, to our knowledge, such an endeavor has never been performed. BACKGROUND

Treatment of Barrow type ‘B’ carotid cavernous fistulas with flow diverter stent (Pipeline)

“…14 The transvenous approaches have now been proved to be the first option for patients with CCFs. 10 The transvenous approach has a low risk and 90% success rate in all CCF cases, with a higher clinical and anatomical cure rate. 7,8 However, it is necessary to discriminate between clinical and angiographic success.…”

“…9,[19][20][21][22][23] An approach of combining direct access to the SOV along with blind probing of the proximal occluded SOV has also been described. 10 The potential complications of blind catheterisation of a thrombosed vein include perforation during advancement of the sharp microwire. 10 The superior petrosal sinus and pterygoid plexus may serve as alternative routes when it receives significant venous drainage from CCFs.…”

“…10 The potential complications of blind catheterisation of a thrombosed vein include perforation during advancement of the sharp microwire. 10 The superior petrosal sinus and pterygoid plexus may serve as alternative routes when it receives significant venous drainage from CCFs. 24,25 The direct exposure of the SOV approach (surgical exposure with anterior orbitotomy) and retrograde catheterisation is used if the facial vein cannot be visualised or is seen to be too tortuous, and if the SOV was sufficiently dilated and if there was significant venous drainage to the SOV.…”

“…8 The problem arises when there is no vascular access. For these cases, different approaches to treat a symptomatic CCF have been described, such as: direct access to the SOV (the vein is surgically exposed and then catheterised); 9 an approach of combining direct access to the SOV along with blind probing of the proximal occluded SOV; 10 and a direct puncture of the cavernous sinus. 11,12 But these techniques are very aggressive and can cause serious complications, such as perforation during advancement of the sharp microwire, intra or retro-orbital haematoma, optic nerve injury, ICA injury, or infections.…”

Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

“…[ 4 , 10 ] In these cases, other transvenous routes can be considered, like the anterior approach through a facial vein or SOV. Some cases of blind direct cannulation of the SOV along with its potential complications[ 1 , 4 ] and direct surgical exposure of the SOV with anterior orbitotomy were described in the past. [ 4 , 16 ] The placement of a flow diverter in the ICA was previously described for the treatment of direct CCFs – or Barrow A-type – as un uncommon option only in some case reports.…”