Carotid cavernous fistula transvenous embolization

Carotid cavernous 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.

Angioplasty of the dural sinus has rarely been performed for the treatment of cavernous sinus dural arteriovenous fistulas. Ide et al. evaluated the efficacy of selective transvenous embolization (TVE) combined with balloon angioplasty of the occluded inferior petrosal sinus (IPS) for the treatment of cavernous sinus dural arteriovenous fistulas (CSDAVFs).

Materials and methods: A total of 8 consecutive patients with CSDAVFs with occlusion of the IPS treated by selective TVE with balloon angioplasty of the IPS from July 2018 to January 2019 were retrospectively reviewed. There were 6 females and 2 males with an average age of 77.6 years. All patients showed ocular symptoms. Angiography showed cortical venous reflux in 7 cases and localized shunted pouches at the medial portion of the cavernous sinus, intercavernous sinus, or laterocavernous sinus. Selective TVE was performed via the occluded IPS with bilateral femoral venous approaches, and the occluded IPS was reconstructed by angioplasty with a 2- to 3-mm diameter balloon during or after selective TVE.

Results: CSDAVFs disappeared immediately after treatment, and the occluded IPSs were successfully reconstructed with re-establishment of normal antegrade venous flow in all cases. No complications were observed, and symptoms resolved within 2 weeks after treatment. During the 7-month mean follow-up period (range 1-12 months), no cases showed recurrence of CSDAVFs.

Conclusion: Selective TVE combined with balloon angioplasty of the occluded IPS is safe and effective for the treatment of CSDAVFs and re-establishes normal venous circulation in selected cases with localized shunted pouches 1)

We present our experience with the unilateral across-the-midline approach to both cavernous sinuses to treat shunts according to anatomical compartments to achieve anatomical cure.

Patients included in this study presented with either bilateral or unilateral shunts with unilateral venous drainage. We used a trans-arterial guiding catheter for road mapping and control angiography. A venous tri-axial 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.

Five patients underwent complete occlusion in a single session. One patient required additional complimentary trans-arterial embolization. Despite a successful unilateral approach to bilateral cavernous sinuses, one patient needed an additional ipsilateral trans-ophthalmic vein 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.

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 2).

With increasing experience and technological advances, transvenous embolization has become the treatment of choice since the 1990s. Today, the venous drainage of CCFs is of greater importance for the management of these lesions and has to be a key component of any contemporary classification system 3) 4) 5).

Ide S, Kiyosue H, Shimada R, Hori Y, Okahara M, Kubo T. Selective transvenous embolization combined with balloon angioplasty of the occluded inferior petrosal sinus for the treatment of cavernous sinus dural arteriovenous fistulas. Interv Neuroradiol. 2021 May 6:15910199211016234. doi: 10.1177/15910199211016234. Epub ahead of print. PMID: 33957799.
Nossek E, Lombardo K, Schneider JR, Kwan K, Chalif DJ, Setton A. Unilateral Venous Approach to Contralateral or Bilateral Carotid Cavernous Shunts. World Neurosurg. 2019 Sep 18. pii: S1878-8750(19)32484-2. doi: 10.1016/j.wneu.2019.09.054. [Epub ahead of print] PubMed PMID: 31541756.
Satomi J, Satoh K, Matsubara S, Nakajima N, Nagahiro S. Angiographic changes in venous drainage of cavernous sinus dural arteriovenous fistulae after palliative transarterial embolization or observational management: a proposed stage classification. Neurosurgery. 2005;56(3):494–502; discussion 494-502.
Stiebel-Kalish H, Setton A, Nimii Y, et al.. Cavernous sinus dural arteriovenous malformations: patterns of venous drainage are related to clinical signs and symptoms. Ophthalmology. 2002;109(9):1685–1691.
Suh DC, Lee JH, Kim SJ, et al.. New concept in cavernous sinus dural arteriovenous fistula: correlation with presenting symptom and venous drainage patterns. Stroke. 2005;36(6):1134–1139.
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