Treatment of carotid-cavernous sinus fistulas using a superior ophthalmic vein approach

Abstract

The authors describe the method and results of treatment of 12 consecutive patients with carotid-cavernous sinus fistulas (CCFs). Treatment was by embolization via a transvenous approach through the superior ophthalmic vein (SOV). The CCFs (two direct and 10 dural) had previously been treated unsuccessfully or, for mechanical reasons, could not be treated by the standard techniques of endoarterial balloon occlusion, particle or glue embolization of feeding vessels from one or both external carotid arteries, or transvenous occlusion of the fistula via the ipsilateral inferior petrosal sinus. All 12 patients were successfully treated either by advancement of a detachable balloon catheter through the ipsilateral SOV into the cavernous sinus with subsequent inflation and detachment of the balloon (11 patients) or by introduction of multiple thrombogenic coils into the fistula via the ipsilateral SOV (one patient). All patients had complete resolution of symptoms and signs after successful occlusion of the CCF. There were no intraoperative complications; however, one patient required postoperative embolization of a residual posteriorly draining fistula via the ipsilateral external carotid artery, and another developed a persistent abducens nerve paresis that eventually required surgical correction. Ten (83.3%) of the 12 patients underwent cerebral angiography 3 to 6 months after surgery, and none showed evidence of a recurrent fistula. Similarly, none of the 12 patients developed recurrent symptoms and signs suggesting recurrence of the fistula during a follow-up period that ranged from 6 months to 10 years (mean 64 months). It is concluded that the transvenous approach to the cavernous sinus through the SOV is a safe and effective treatment of both direct and dural CCFs that are not amenable to transarterial or other transvenous approaches.

Transarterial and Transvenous Embolization for Cavernous Sinus Dural Arteriovenous Fistulae

“…We think that our results compare quite favorably with recent studies of endovascular treatment of patients with cavernous sinus DAVFs. Miller et al reported the results of ten patients with Types B to D cavernous sinus DAVFs treated transvenously, several patients (number not specified) experienced transient ocular motor dysfuncion; one patient developed new VI cranial nerve weakness, which did not resolve and necessitated later strabismus surgery 20 . Roy and Raymond treated 12 patients with cavernous sinus DAVFs treated with either a transarterial, transvenous or combined endovascular approach, transient VI cranial nerve weakness was observed for five patients (42%); one patient experienced permanent abducens palsy 25 .…”

“…Endovascular techniques have become the most common treatment for patients with symptomatic cavernous sinus DAVFs that do not spontaneously resolve, because of the high rates of cure after emboliza-A B C D tion 2,6,10,14,24 . However, embolization of cavernous sinus DAVFs has been reported to cause at least temporary ophthalmoplegia in eight to 50% of patients 1,20 , and recanalization of embolized DAVFs is well documented 26 . Direct surgical treatment is difficult and is associated with high rates of postoperative cranial nerve deficits 27 .…”

Long-Term Endovascular Treatment Outcome of 46 Patients with Cavernous Sinus Dural Arteriovenous Fistulas Presenting with Ophthalmic Symptoms

“…Endovascular techniques are the most commonly used treatment for patients with symptomatic cDAVFs that do not spontaneously resolve. However, recent investigations have indicated that embolization of cDAVFs is not a thoroughly safe procedure and may also be related to temporary ophthalmoplegia [10][11][12] . Not only are the surgical approaches difficult, but cDAVF embolization has a high rate of postoperative cranial nerve deficit and associated occlusion of the ICA 13 .…”

Triple Coaxial Catheter Technique for Transfacial Superior Ophthalmic Vein Approach for Embolization of Dural Carotid-Cavernous Fistula

“…Both transarterial 4,5 and transvenous 1-3 approaches have been adopted. The transvenous approach has been shown by several studies to have a better clinical outcome and anatomical cure rate [5][6][7][8][9][10] . Among the transvenous approaches, IPS and facial vein through SOV 2 are the two most widely described routes of choice.…”

“…The transvenous approach is preferred due to higher clinical and anatomical cure rate [5][6][7][8][9][10] . There are various transvenous routes in embolization of DCCF 11 .…”