Transvenous embolization of dural carotid cavernous fistula through the facial and ophthalmic vein

Abstract

Dural carotid cavernous fistula is acquired, relatively rare, condition comprising of numerous small-caliber meningeal arterial branches, draining directly into cavernous sinus. Endovascular therapy is the treatment of choice, preferably by a transvenous approach. In the case of inaccessible inferior petrosal sinus, other alternative routes are considered. We presented a case of dural carotid cavernous fistula completely occluded with Guglielmi detachable coils, using a transvenous approach through facial and superior ophthalmic vein. A 62-year-old man was referred with a gradual worsening proptosis, red eye, and decreased visual acuity, on the right side. Digital subtraction an giography revealed the presence of a right dural carotid cavernous fistula, predominantly supplied from dural branches of the right internal carotid artery siphon, with minimal contribution from the right middle meningeal artery and contra lateral dural branches of the left internal carotid artery siphon. The fistula was drainaged through the dilated superior ophthalmic vein, and via the facial to the internal jugular vein. There was neither pacification of pterygoid and petrous sinuses, nor cortical venous reflux. Endovascular treatment was performed by a transvenous approach. A guiding catheter was placed in the right facial vein. A microcatheter was advanced through the dilated angular and superior ophthalmic vein, and its tip positioned into the right cavernous sinus. Coils were deployed, until a complete angiographic occlusion of the fistula had been achieved. The patient experienced rapid improvement in the symptoms, with complete normalization of his condition one month after the treatment. Coil embolization of dural carotid cavernous fistula by transvenous catheterization, through the facial and superior ophthalmic vein, can be considered as safe and effective treatment option in the presence of marked anterior drainage.