Transvenous approach to carotid–cavernous fistula via facial vein cut down

Abstract

Endovascular access to carotid–cavernous sinus fistulae (CCF) can be obtained through a transfemoral approach to the inferior petrosal sinus (IPS) or superior ophthalmic vein (SOV). If the transfemoral approach cannot be utilized, direct surgical exposure of the SOV can provide access to the CCF. The authors present an alternate approach to a CCF in a 66-year-old woman in whom the IPS was thrombosed and the facial vein so tortuous at its origin that it could not be passed with a wire. The facial vein was exposed surgically at the angle of the mandible after percutaneous attempts failed. After localization of the anterior facial vein with ultrasound, a 1cm skin incision was made over the margin of the mandible. The dissected vein was cannulated using a micropuncture technique and a 0.018 inch wire. A four French short access sheath was inserted and sutured to the vein. Subsequent venogram allowed navigation of an SL-10 microcatheter over a Synchro soft microwire (both Boston Scientific, Natick, MA, USA) via the SOV into the cavernous sinus, and coil embolization was performed with angiographic cure of the fistula. No complications were encountered and the cosmetic result of the small incision of the mandibular region was excellent and less conspicuous than it would have been on the eyelid. This technical note illustrates that facial vein cut down is an attractive and safe alternate approach to endovascular management of CCF via a transvenous route in patients with a focally narrowed and tortuous IPS and common facial vein.