Transvenous Endovascular Embolization Research Articles

Transvenous Embolization of Cerebrospinal Fluid-Venous Fistulas: Pearls, Pitfalls, and Lessons Learned

Cerebrospinal fluid-venous fistulas (CSFVFs) are increasingly recognized as a cause of spontaneous intracranial hypotension (SIH), a debilitating neurologic condition that may present with postural headaches, hearing loss, and/or cognitive impairment. Curative treatment is available for patients whose fistulas are localized with myelography. Transvenous endovascular embolization has emerged in recent years as a safe, effective, and durable treatment option for patients with CSFVF. Here, we briefly review the clinical presentation of SIH, present diagnostic algorithm by which CSFVFs are identified, and discuss a stepwise treatment paradigm. We then detail endovascular treatment strategies of CSFVF with particular emphasis on direct versus indirect approaches to the fistula, embolization principles, and techniques to minimize complications. With increasing awareness of SIH and enhanced detection of CSFVF, it is important for endovascular neurosurgeons and neurointerventionalists to be familiar with transvenous CSFVF embolization strategies to meet the needs of this patient population.

Direct Transverse Sinus Puncture for Transvenous Coil Embolization of Vein of Galen Malformations: Innovating Existing Techniques.

Vein of Galen malformations (VOGMs) are complex arteriovenous malformations in neonates and young children. Recent advances in endovascular interventions have drastically improved treatment and clinical outcomes in what was previously high-morbidity, high-mortality disease. The high-flow shunt pathophysiology in VOGMs can lead to dynamic changes in the malformation angioarchitecture, and over time patients can develop jugular bulb stenosis. In the setting of inaccessible transvenous access to the malformation for endovascular embolization in cases where transarterial embolization is inadequate, a combined surgical and endovascular technique must be used. We present the first successful modern-day application of direct puncture through transverse sinus for transvenous embolization of a VOGM. We present 2 unique cases of complex VOGM malformations in patients who had previously undergone staged endovascular embolization for reduction of flow within the malformation. On follow-up, in both cases, there was development of severe sigmoid sinus and jugular bulb stenosis, increasing intracranial venous congestion and causing marked clinical deterioration. The stenosis prevented traditional transvenous access and treatment. We describe a direct puncture transverse sinus access using a burr hole approach for endovascular transvenous embolization in both cases with successful clinical outcomes. Direct access using burr hole craniotomy to the transverse sinus for transvenous endovascular embolization is a safe approach in the setting of severe jugular bulb stenosis for treatment of VOGMs. This technique can be done efficiently to achieve complete flow elimination in the malformation, in cases where that is called for, without significant risks or complications related to the approach.

Transvenous embolization of conus spinal arteriovenous malformation: illustrative case

Spinal arteriovenous malformations (AVMs) are the most challenging spinal vascular malformations. Endovascular transarterial embolization of spinal AVM has been well described. However, transvenous embolization has not been previously reported. In this case report, the authors describe transvenous embolization of a recurrent intramedullary/conus spinal AVM that was previously deemed unamenable to endovascular therapy. A 30-year-old female presented with debilitating lumbar back pain and was found to have an intramedullary spinal AVM at the level of the conus medullaris. Initially, the AVM was treated with endovascular arterial embolization and subsequently with microsurgical resection. However, on follow-up angiography, the AVM had recurred. Further arterial embolization was deemed not possible because of anatomical challenges. After careful consideration, endovascular transvenous embolization was performed with successful occlusion of the AVM nidus. Transvenous embolization is an alternative route for endovascular treatment of spinal AVMs that have an accessible single draining vein.

Perioperative Complications of Transvenous Embolization of Ruptured Intracranial Arteriovenous Malformations.

PurposeTo investigate the perioperative complications of transvenous embolization of ruptured intracranial arteriovenous malformations.Materials and MethodsA total of 27 patients with ruptured intracranial arteriovenous malformations underwent transvenous embolization were enrolled from November 2016 to May 2020 in our prospective database. Perioperative complications and angiographic characteristics were analyzed retrospectively.ResultsComplete disappearance of the nidus occured in 22 (88%) of 25 patients with technically feasible AVMs immediately after embolization. Two cases were partially treated by transarterial embolization due to the failure of microcatheter placement into the draining vein. Seven (25.9%, 7/27) patients had perioperative complications, including three cases of intraoperative hemorrhage, three cases of postoperative hemorrhage and one case of ischemic infarction. No significant differences in complication rates between patients with nidus ≥3 cm and <3 cm (P = 0.659), eloquent area and non-eloquent (P = 0.137), deep location and superficial (P = 0.637), deep venous drainage and cortical vein (P = 1.0), the number of venous drainage (P = 0.49), the angle of draining vein entering venous sinus <90° and ≥90° (P = 1.0), aneurysms (P = 0.058) and the time between hemorrhage and TVE (P = 1.0) were found. Three of these patients received ventriculostomy, two of which received lumbar drainage treatments at the same time, and four patients just received conservative management. Good outcomes (mRS ≤ 2) at the 1-month evaluation were achieved in 5 of the patients who had complications, but poor outcome (mRS = 5) at the 1-month evaluation was in 1 patient, and 1 lethal complication occurred.ConclusionThe most common complication of AVMs with transvenous endovascular embolization is cerebral hemorrhage. The prevention of complications may improve the efficacy of AVM embolization, but the current quality of evidence is low and limited in guiding policy development and improving the TVE for AVMs. It is, therefore, necessary to develop clinical research programs in this field.

Adenosine-induced transient circulatory arrest in transvenous embolization of cerebral arteriovenous malformations.

Due to advances in interventional techniques, the transvenous approach may present an effective treatment option for embolization of brain arteriovenous malformations (AVMs). Contrary to the transarterial method, the transvenous approach can only be utilized in a specific subset of patients and is not suitable as a standard procedure for all AVM lesions. While this technique can be helpful in certain patients, careful patient selection to ensure patient safety and favorable clinical outcomes is important. However, especially in high-flow AVMs, targeted deposition of embolic materials through a transvenous access can be challenging. Therefore, a temporary flow arrest may prove helpful. Transient cardiac arrest by use of adenosine has been applied in cerebrovascular surgery but is not common for endovascular embolization. Adenosine-induced arrest and systemic hypotension may be a feasible, safe method to reduce flow and help endovascular transvenous embolization of certain AVMs. Our study evaluated the efficiency and safety of adenosine-induced circulatory arrest for transvenous embolization of cerebral AVMs.

Superficial middle temporal vein as a pivotal route to embolize dural carotid–cavernous fistulas

Dural carotid–cavernous fistulas (DCCF) are located in the cavernous sinus wall involving the arterial feeders from the external and internal carotid arteries. The venous route usually passes through the internal jugular vein and inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In cases of a thrombosed IPS, catheterization is not always possible because of the obstruction. Here, we report eight cases of DCCF treated with endovascular transvenous embolization via the superficial middle temporal vein (SMTV). A retrospective study involving eight patients with DCCF treated with transvenous embolization via SMTV was performed. In six patients, IPS was thrombosed. In one patient, IPS was patent, but we could not catheterize the internal jugular vein. In the other patient, because of the compartmentalization of the cavernous sinus, we could not access the anterior part of the cavernous sinus via IPS. Therefore, we performed the embolization via SMTV to occlude the shunts of the anterior part of the cavernous sinus.In all eight cases, navigating through the tortuous junction of the angular vein and superior ophthalmic vein (SOV) was possible. After transvenous catheterization of the cavernous sinus via SMTV, placement of coils resulted in complete occlusion of DCCF with clinical improvement in all eight patients. In the endovascular treatment of DCCF, the transfemoral approach via SMTV provides a pivotal route alternative to other transvenous routes. In patients with dilated SOV, catheterization of the cavernous sinus via SMTV is usually successful.

Operative Nuances of Blind Catheterization of Occluded Sinuses Using Negative Road Map Technique: 2-Dimensional Operative Video.

Dural arteriovenous fistula (DAVF) are often treated with endovascular transvenous embolization. DAVFs though, are often associated with intracranial venous sinus occlusion, which limits the transvenous route. Here, we present the operative nuances of blind catheterization of an occluded dural venous sinus in 2 different cases with DAVF. First case is a 72-yr-old patient with indirect right carotid-cavernous fistula associated with an occluded inferior petrosal sinus, with severe orbital congestion. Second patient is a 79-yr-old patient with a new external carotid to a trapped transverse sinus fistula (Cognard IIA+B), extensive cortical venous reflux in the setting of an occluded sigmoid sinus. In both cases, the transarterial route was limited because of small arterial feeders thus, after obtaining patients' consent, we performed transvenous sacrifice of the isolated sinus. In both cases, the occluded sinus was transvenously blindly retrograde probed using a 0.035 inch Terumo Glidewire (Terumo Medical Corporation, Somerset, New Jersey). Once the occluded segment was probed, a dark roadmap was acquired with the wire in place. This created a negative roadmap once the guidewire is removed. This negative roadmap is used to navigate the microcatheter-microwire into the isolated sinus. In the first case, the cavernous sinus and the superior ophthalmic veins were sacrificed with coils. In the second patient, the entrapped left transverse sinus was embolized using Onyx. In both cases, complete occlusion of the fistula was attained. In this neuroendovascular video, we demonstrate the nuances of blind catheterization of an occluded sinus using a negative roadmap technique as guidance for the micro-catheterization. Institutional Review Board approved. Patient consent not required due to retrospective nature of manuscript, based on medical chart and imaging reviews, anonymized in the video.

Selection of Patients for Treatment of Brain Arteriovenous Malformations by the Transvenous Approach: Relationship with Venous Anatomy and Risk of Hemorrhagic Complications.

Intracranial hemorrhage represents a severe complication of brain arteriovenous malformation treatment. The aim of this cohort was to report the rate of hemorrhagic complications after transvenous endovascular embolization and analyze the potential angioarchitectural risk factors as well as clinical outcomes. During an 11-year period, 57 patients underwent transvenous endovascular embolization. All cases of hemorrhagic complications were identified. We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM before the transvenous treatment, number of venous collectors, pattern of drainage, presence of dilated veins, and technical aspects. Univariate and multivariate multiple regression analyses were performed to evaluate the potential risk factors for procedure-related hemorrhagic complications. Hemorrhagic complications (either intraprocedural or periprocedural) unrelated to a perforation due to micronavigation occurred in 8 (14.0%) procedures. Significant (mRS > 2) and persistent neurologic deficits were present in 2 (3.5%) patients at 6-month control. Larger nidi, especially >3 cm (P = .03), and a larger number of venous collectors have shown a statistically significant correlation with hemorrhagic complications. Only the number of venous collectors was identified as an independent predictor of hemorrhagic complications in the multivariate analysis (OR, 8.7; 95% confidence interval, 2.2-58.2) (P = .006). Larger nidus sizes and an increased number of venous collectors may increase the risk of hemorrhagic complications when implementing transvenous endovascular treatment of AVMs. The technique is effective and promising, especially with small nidi and single venous collectors.

Adenosine-Induced Cardiac Arrest for Transvenous Embolization of Midbrain Arteriovenous Malformation.

Few studies describe the use of adenosine-induced cardiac systole for treatment of cerebrovascular pathologies.We describe a midbrain arteriovenous malformation (AVM) treated with transvenous embolization using adenosine-induced asystole to achieve transient systemic hypotension with the purpose of furthering discussion on the technique and operative considerations for adenosine use in endovascular AVM treatments. A 29-yr-old man presented with sudden onset of severe bilateral headache, blurred vision, and numbness on the right side of his face and tongue. Noncontrast head computed tomography revealed fourth ventricle hemorrhage. Diagnostic cerebral angiography revealed a high-flow midbrain AVM with a posterior wall perforator from the basilar artery terminus and a draining vein into the straight sinus. Transarterial AVM embolization was successful. The patient was discharged with no residual neurological deficits but returned 1 wk later with slurred speech and left-sided dysmetria. Repeat angiography revealed partial AVM filling. Attempts at transarterial embolization were unsuccessful. Thus, transvenous AVM embolization with adenosine-induced cardiac asystole and systemic hypotension was performed. A total of 60 mg of adenosine was administered, followed by 2 additional doses of 60 and 40 mg; and complete cardiac asystole with a mean arterial pressure of 40 mmHg was maintained, resulting in successful embolization of the AVM. No residual filling was visualized on postembolization arterial angiography runs. The patient was neurologically stable and discharged on postoperative day 2. With appropriate and safe dosing, adenosine-induced asystole and systemic hypotension may be a feasible, safe option to reduce flow and assist endovascular transvenous embolization of high-flow AVMs.

Endovascular transvenous treatment for superficial intracranial arteriovenous malformations

ObjectiveThe objective of this study was to evaluate the feasibility and outcomes of transvenous endovascular embolization (TVE) for superficial intracranial arteriovenous malformations (AVMs). MethodsAfter collecting clinical and imaging data, a prospective series of 11 patients presenting with superficial AVMs were treated by endovascular embolization using a transvenous approach between November 2016 and October 2018. ResultsTen patients (90.9%) had ruptured AVMs before TVE. The mean nidus size was 3.27 ± 1.47 cm, and the median Spetzler-Martin grade was II. The rate of immediate angiographic occlusion of the AVMs was 90.9% (10/11). One patient was treated with transarterial embolization since TVE was not achieved due to an unsuccessful positioning of the microcatheter. Two patients (cases 8 and 11) suffered a intracranial hemorrhage and a cerebral infarction with encephaledema, respectively, but no procedure-related mortalities were observed. Eight patients (72.7%) were independent with a modified Rankin Score (mRS) ≤ 2 at discharge and the mRSs of all patients, which were collected 30 days postintervention, were not more than 2. The mean follow-up period was 17 months. There were no nidus recurrences during the follow-up period. ConclusionsThe curative transvenous embolization of superficial AVMs seems feasible and effective while carefully monitoring for embolization-related complications.

Resection of an Embolized Cirsoid Aneurysm With Intracranial Venous Drainage: 2-Dimensional Operative Video.

Cirsoid aneurysms, also known as scalp arteriovenous malformations (AVM), are rare congenital extracranial vascular anomalies that often present as an enlarging pulsatile scalp mass. A 14-yr-old male presented with a pulsatile scalp lesion that was first noticed 3 yr prior and had progressively enlarged. No history of trauma was reported. MRI demonstrated a 4 cm wide and 2 cm tall nidus and catheter angiography was performed to further define the vascular supply and drainage. The patient underwent transvenous endovascular embolization followed by surgical excision via a bicoronal incision, as shown in this operative video. Care was taken to identify, cauterize, and transect feeding vessels from the superficial temporal, supratrochlear, and supraorbital arteries circumferentially to completely devascularize and resect the galeal nidus from overlying scalp tissue and underlying pericranium. Previously unreported in the literature, transosseous emissary veins partially draining the lesion were noted on angiography and were waxed thoroughly during surgery. Six-month follow-up examination demonstrated a well-healed incision without evidence of AVM recurrence. The unique venous drainage of this cirsoid aneurysm highlights the value of diagnostic angiography to fully characterize these rare and complex vascular lesions prior to pursuing definitive treatment. IRB approval was obtained from the Ann & Robert H. Lurie Children's Hospital of Chicago Institutional Review Board (IRB #2018-1799). The IRB waives the requirement of obtaining informed consent for this study in accordance with 45 CFR 46.116(d).

Curative Transvenous Embolization for Ruptured Brain Arteriovenous Malformations: A Single-Center Experience from China

To evaluate feasibility and safety of transvenous embolization for brain arteriovenous malformations (AVMs). Between November 2016 and August 2017, a transvenous endovascular embolization protocol was implemented at the Henan Provincial People's Hospital for consecutive patients with ruptured brain AVMs. Therapeutic decision making was based on Spetzler-Martin grade, brain AVM location, pattern of venous drainage, and angioarchitecture. Transvenous embolization was combined with transarterial support. Complete angiographic obliteration of the nidus was the objective of treatment. Among 10 patients with ruptured brain AVMs, 8 were male. Spetzler-Martin grades before transvenous embolization were IV in 3 patients, III in 5 patients, II in 1 patient, and I in 1 patient. Modified Rankin Scale score before the procedure was 0-2 for 6 of 10 patients. Five patients also had deep venous drainage. Arterial blood pressure control and venous pressure cooker technique were used in all 10 patients; 9 patients had immediate angiographic occlusion. Two patients had a ventricular hemorrhage, which did not cause any disability after medical treatment. Seven patients underwent angiography 3-5 months after the procedure, and complete obliteration of the nidus was confirmed. Median clinical follow-up for all 10 patients was 8 months (range, 3-12 months). Epilepsy occurred in 1 patient 3 months after the procedure, and modified Rankin Scale scores for all patients were ≤1. Transvenous embolization of brain AVMs is feasible and may improve cure rates. The safety and long-term effects need further validation.

Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus.

Combined transarterial balloon-assisted endovascular embolization with double-lumen balloon microcatheters and concomitant transvenous balloon protection was described as a promising treatment technique for dural arteriovenous fistulae of the transverse and sigmoid sinus. The purpose of this study was to evaluate the technical efficacy and safety of this combined treatment technique. Nine consecutive patients presenting with dural arteriovenous fistulas of the transverse and sigmoid sinuses underwent combined transarterial and transvenous balloon-assisted endovascular embolization. Prospectively collected data were reviewed to assess the technical success rate, complication rate, and clinical outcome. Six patients presented with clinically symptomatic Borden type I, and 3 patients, with Borden type II dural arteriovenous fistulas of the transverse and sigmoid sinuses (3 men, 6 women; mean age, 50.4 years). Transarterial embolization was performed with a double-lumen balloon with Onyx and concomitant transvenous sinus protection with a dedicated venous remodeling balloon. Complete angiographic occlusion at the latest follow-up (mean, 4.8 months) was achieved in 6 patients, and near-complete occlusion, in 2 patients. Clinical cure or remission of symptoms was obtained in 6 and 2 patients, respectively. One patient with a residual fistula underwent further treatment in which the dural arteriovenous fistula was cured by sinus occlusion. Complete occlusion of the dural arteriovenous fistula was visible on the follow-up angiography after final treatment in 8 patients. One patient refused follow-up angiography but was free of symptoms. There were no immediate or delayed postinterventional complications. Transarterial balloon-assisted embolization of dural arteriovenous fistulas of the transverse and sigmoid sinuses with combined transvenous balloon protection is safe and offers a high rate of complete dural arteriovenous fistula occlusion and remission of clinical symptoms.

Transorbital Approach for Endovascular Occlusion of Carotid-Cavernous Fistulas: Technical Note and Review of the Literature.

Carotid-cavernous fistulas (CCFs) pose an anatomically and physiologically challenging problem for clinicians. The most common method of treatment for these lesions is transvenous endovascular embolization via the inferior petrosal sinus or the facial vein. When transvenous access is not possible, an alternate approach must be devised. We describe a case example with bilateral Barrow Type B CCFs, which were inaccessible using the traditional transvenous approach. Hence, a direct transorbital approach, performed under fluoroscopic guidance, was employed to successfully obliterate the CCF. At five months follow-up, the patient was recovering without complications. This case delineates the technical aspects of transorbital CCF embolization and demonstrates that this approach is a viable alternative to conventional transvenous methods for appropriately selected CCF cases. We supplement our case example and technical note with a literature review of this approach.

Surgical Treatment of Spinal Extradural Arteriovenous Fistula With Parenchymal Drainage

Abstract BACKGROUND AND IMPORTANCE: Spinal extradural arteriovenous fistula (SEDAVF) with parenchymal drainage (type A) is a rare clinical entity that causes venous congestive myelopathy. Treatment includes endovascular and open microsurgical interventions. We reviewed the clinical records of patients treated for a type A SEDAVF to evaluate the feasibility of our treatment strategy. CLINICAL PRESENTATION: Between 2004 and 2010, 5 patients with a type A SEDAVF were treated at our institutes (4 men and 1 woman; mean age, 60 years). We performed endovascular transvenous embolization (TVE) when lesions were accessible transvenously; otherwise, microsurgical perimedullary drainer occlusion was performed. Follow-up ranged from 23 to 94 months (mean, 45.8 months). One patient was treated with TVE, and the remaining 4 were treated with microsurgical drainer occlusion. After a simple intradural drainer occlusion, an epidural venous lake was completely thrombosed in 2 patients. In 1 patient, postoperative angiography revealed that a part of the epidural component had persisted; however, the patient has been asymptomatic. In the remaining case with multiple intradural draining veins, sole drainer occlusion was not sufficient. A second surgery was required to meticulously coagulate the venous lake. As a consequence, parenchymal drainers disappeared. Overall, all patients stabilized or improved neurologically and experienced no recurrence. CONCLUSION: To treat a type A SEDAVF, either TVE or microsurgical intradural drainer occlusion can be used for satisfactory long-term results with minimal surgical risks. For a case with multiple intradural draining veins, detachment of the venous lake should be considered.

Transvenous Coil Embolization of an Intraorbital Arteriovenous Fistula

Purely intraorbital arteriovenous fistulas (AVFs), which are rare vascular malformations that clinically mimic carotid-cavernous fistulas (CCFs), involve a fistula from the ophthalmic artery to 1 of the draining ophthalmic veins. We describe a case of an intraorbital AVF treated with transvenous endovascular coil embolization via the inferior petrosal sinus (IPS) route and review the literature on this rare entity. An 81-year-old woman sought treatment after 7 days of progressive left-sided visual acuity loss, chemosis, and lateral rectus palsy. Magnetic resonance imaging demonstrated dilated vascularity in the left orbit raising suspicions for a CCF. Cerebral angiography showed a purely intraorbital AVF with a fistula between the left ophthalmic artery and superior ophthalmic vein (SOV). Transvenous selective catheterization of the fistula was performed by successfully navigating the ipsilateral IPS to the cavernous sinus and SOV. The fistula was then embolized using detachable coils. The patient was discharged the next day. Three weeks after embolization, her ocular symptoms and findings had resolved. Intraorbital AVFs are a rare type of AVF that can be treated by direct surgical ligation, transarterial embolization, or transvenous embolization. We successfully navigated the IPS, which is frequently stenotic or occluded secondary to chronically increased fistulous drainage, and utilized this route to embolize the fistula with detachable coils.

Successful Transvenous Embolization of Brain Arteriovenous Malformations Using Onyx in Five Consecutive Patients

There is an increasing application of endovascular treatment for brain arteriovenous malformations (BAVMs) using ethylene vinyl alcohol copolymer (Onyx). Historically, this treatment has been performed using a transarterial approach. To report our experience with transvenous endovascular embolization with Onyx (TVEO). Five consecutive patients with BAVMs underwent endovascular TVEO between June 2007 and March 2009 at the Interventional Neuroradiology Department of the University Hospital of Limoges. There were 3 men and 2 women with a mean age of 41.8 years (range, 19-57 years). The clinical presentation included symptoms caused by intracerebral hemorrhage (n = 4) and seizures (n = 1). According to the Spetzler-Martin classification scheme, 3 BAVMs (60%) were grade III, and 2 BAVMs (40%) were grade IV. Four BAVMs (80%) were supratentorial and 1 BAVM (20%) was infratentorial. Immediate and mid-term treatment (6 months) outcomes were angiographically and clinically analyzed according to the modified Rankin Scale. The transvenous approach was used in all patients (100%). The success rate of complete obliteration of the arteriovenous malformation nidus was 80% (4 of 5), confirmed by follow-up angiography performed immediately and at 6 months after TVEO. No procedure-related complications occurred during or after embolization. All patients remained unchanged (modified Rankin Scale score = 0-2) and clinically stable 6 months after TVEO. The transvenous approach using Onyx for the management of BAVMs is shown to be an efficient and safe alternative treatment in cases with no other conventional therapeutic choice and when some anatomic considerations are respected.

E-041 Combined endovascular embolization and surgical resection of a massive lumbosacral arteriovenous malformation in a patient with Cobb syndrome

Objective and importanceCobb syndrome is a rare condition that includes a cutaneous nevus with an associated spinal vascular lesion at the same dermatome. We present a challenging case of a...

Endovascular Transvenous Embolization Combined with Direct Punction of the Sinus Pericranii

Sinus Pericranii is a rare venous anomaly in which the communication between the intra- and extracranial venous system is constituted by a network of thin-walled veins that form a varix on the external table of the skull. This varix is continuous with the pericranial veins of the scalp. We describe a 31-year-old woman with frontal sinus pericranii treated using an original endovascular technique by transvenous approach combined with direct punction.

Transcutaneous Puncture of the Superior Ophthalmic Vein for Embolization of Dural Carotid-Ophthalmic Fistula

Carotid-ophthalmic fistula is a rare disease, which can be treated by transvenous endovascular embolization. Here, we report a unique case with draining vein thrombosed, making a transvenous approach impossible. An old but valuable technique, direct transcutaneous puncture of the superior ophthalmic vein, was used to save the patient's right eye. The old technique, direct puncture of the superior ophthalmic vein, retains its irreplaceable usefulness in this special situation. Thus, interventional neuroradiologists should equip themselves with this essential technique.