Download Endovascular Treatment of Cavernous Sinus Dural Arteriovenous

J Radiol Sci 2011; 36: 129-134
Endovascular Treatment of Cavernous Sinus Dural
Arteriovenous Fistulas by Direct Puncture of Facial Vein
Shih-Wei Hsu1 Yeh-Lin Kuo1 Min-Hsiung Cheng2
Department of Diagnostic Radiology1 and Neurosurgery2, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College
of Medicine, Kaohsiung, Taiwan
ABSTRACT
Transvenous embolization through the superior ophthalmic vein (SOV) is one of the most effective treatments for
cavernous sinus dural arteriovenous fistulas (DAVF). We describe a simple application of intravenous catheterization
to approach the SOV with direct percutaneous puncture of the facial vein without a surgical procedure. Contralateral
digital subtracted roadmap and arteriogram in anterior-posterior projection are the best image references to place the
surface markers precisely for the direct percutaneous puncture of the facial vein in such a circumstance.
Intracranial dural arteriovenous fistulas (DAVF)
account for 10 to 15% of all the intracranial arteriovenous
malformations. The cavernous sinus is one of the common
sites of involvement [1]. Endovascular therapy for patients
who required treatment with a transvenous approach
has been described in the literature [2-5]. The superior
ophthalmic vein (SOV) approach for transvenous embolization is one of the effective treatments for cavernous sinus
DAVF when the inferior petrosal sinus approach poses
difficulties. We report a case of cavernous sinus DAVF that
was treated successfully by transvenous embolization from
SOV approach using marker-guided direct percutaneous
puncture of the facial vein.
Case report
A 56-year-old male suffered significant left eye protrusion as well as congestion of the conjunctiva for more
than 3 months before his first visit. Physical examination
revealed proptosis of left eye with marked congestion
of the conjunctiva. Progressive worsening of his vision
was also noted in the recent week. Magnetic resonance
images (MRI) revealed a dilated signal-void SOV in his
left orbital. Angiography disclosed dural or indirect type
arteriovenous fistulas with the arterial feeders from bilateral cavernous segments of internal carotid arties (ICA) and
bilateral external carotid arteries (ECA) branches to the left
cavernous sinus (Barrow Type D). Predominantly venous
drainage was the engorged left SOV and to the left facial
vein (Fig. 1). There was neither significant cortical venous
reflux nor posterior-inferior drainage through the inferior
petrosal sinus (IPS). Transarterial embolizations of bilateral
ECA feeders were performed. The ocular symptoms were
improved after the embolization and rapidly recurred in
three weeks.
Second section of embolization with transvenous
approach was then arranged. The IPS was angiographically blocked without obvious connection of the internal
jugular vein and the cavernous sinus. Although the literature suggests that the IPS could be catheterized in such a
circumstance [3], we still failed to catheterize the IPS. We
Correspondence Author to: Yeh-Lin Kuo
Division of Neuroradiology, Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
No. 123, Ta-Pei Road, Naio-Sung, Kaohsiung 83305, Taiwan
J Radiol Sci June 2011 Vol.36 No.2
129
endovascular treatment of cavernous sinus DaVF
Figure 1
1a
1b
1c
1d
Figure 1. Digital subtracted angiograms of bilateral internal and external carotid arteries (a. lateral view of left internal
carotid artery. b. anterioposterior view of left external carotid artery. c. lateral view of right internal carotid artery. d.
anterioposterior view of right external carotid artery) show the cavernous sinus dural arteriovenous fistulas with feeders
contribute to the left cavernous sinus. The predominant drainage vein is the left superior ophthalmic vein (arrows). There
is no obvious drainage through inferior petrosal sinus. The posterior inferior portion of the left cavernous sinus has a plexiform appearance or partial thrombosis (a, c, arrowheads).
then tried an SOV approach by navigating the microcatheter
from the external jugular vein through the facial vein. The
microcatheter reached the facial vein but could not cannulate through it. The anterioposterior (AP) view of contralateral ICA and ECA angiograms clearly demonstrated the
facial vein and its course which let us decide to try direct
percutaneous puncture of the facial vein to approach the
SOV (Fig. 2). However, the facial vein was not clearly identified from patient’s cheek. We put two small lead markers
on the surface of the patient’s left cheek precisely along the
straight segment of the facial vein by using contralateral
carotid artery angiographic roadmap (Fig. 3). The facial
vein was then carefully punctured with an 18 G intravenous
catheter (IC) needle from the lower marker towards the
130
upper marker. With only several trials, the IC soft needle
was successfully cannulated into the facial vein. After
insertion of a 0.035-inch hydrophilic guide wire, the IC soft
needle was exchanged into a 4 french femoral sheath, which
was inserted into the facial vein for about 3-4 cm in length
and secured with surgical tapes on the patient’s cheek (Fig.
4). A microcatheter was then smoothly navigated through
the facial vein, the SOV and into the left cavernous sinus
without much difficulty. Another intra-arterial diagnostic
catheter was inserted into the right common carotid artery
for monitoring the fistulas during the embolization. Totally
Eleven pushable platinum fibered microcoils (Vortex,
Target Therapeutic/Boston Scientific, Fremont, CA) were
used to pack in two regional compartments of the cavernous
J Radiol Sci June 2011 Vol.36 No.2
endovascular treatment of cavernous sinus DaVF
Figure 2
Figure 2. Right external carotid digital
subtracted angiogram in anteriorposterior projection clearly demonstrates
the early drainage of left facial vein
and its course (arrow).
Figure 3
Figure 3. Digital subtracted right
common carotid angiogram shows
the two small surface lead markers
(arrows) which were placed precisely
on the patient’s left cheek along the
course of the straight segment of the
left facial vein.
sinus (Fig. 5). Post-embolization angiography revealed
complete obliteration of the DAVFs immediately (Fig. 6).
Post-embolization course was uneventful and the patient
recovered from his symptoms shortly. The puncture wound
on the patient’s cheek was minimal and posed no cosmetic
problem. The patient received angiographic follow-up
study eighteen months later revealed complete cure of the
cavernous sinus DAVF. The patient continues to be free of
symptoms after more than 3 years of clinical follow-up.
J Radiol Sci June 2011 Vol.36 No.2
Discussion
Patients with indirect type, or dural type arteriovenous
fistulas (DAVF) involving cavernous sinus can be conservative observation or be treated by radiosurgery or endovascular embolization depending on the severity of the clinical
symptoms and risks of cortical vein reflux. Endovascular
embolization of cavernous DAVF, including transarterial or/
and transvenous approaches, by using various materials can
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endovascular treatment of cavernous sinus DaVF
Figure 4
Figure 4. A 4 French femoral sheath is
placed into the facial vein after cannulation of the facial vein by intravenous
catheter needle. The surface guideline
is seen. (The two lead markers have
already been removed). No surgical
exposure of the vein is required.
Figure 5
5a
5b
Figure 5. Post-embolization non-subtracted radiograms in lateral view a. and anterioposterior view b. show the fibrous
platinum microcoils are packed in two different compartments of the left cavernous sinus (arrowheads). Two linear nonforming fibrous platinum microcoils (arrows) were put in the branches of the external carotid artery at the first transarterial
embolization.
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J Radiol Sci June 2011 Vol.36 No.2
endovascular treatment of cavernous sinus DaVF
Figure 6
6a
6b
Figure 6. Post-embolization digital subtracted angiograms of the right common carotid a. and left common carotid arteries
b. in anterioposterior views show complete obliteration of the left cavernous sinus dural arteriovenous fistulas.
obliterate the fistulas. Transvenous approaches have been
proven safe and effective, and have become the treatment of
choice [2-5]. Many transvenous routes have been reported
in the treatment of cavernous sinus DAVF. The inferior
petrosal sinus (IPS) is one of the most common approaches
when using transfemoral catheterization because the IPS
has a shorter and straighter course. However, the IPS
may be difficult to access because of its plexiform nature,
thrombosis, stenosis or even hypoploasia/aplasia. The SOV
is another approach to the cavernous sinus. Access to the
SOV has been recommended especially when the patient
has predominantly anterior venous drainage though this
vein [6]. Transfemoral approach to SOV usually poses difficulty because there is an abrupt angulation and tortuosity at
the exit of the SOV. Surgical exposure of the SOV may have
a favorable outcome [7]. However, it also carries the risk
of damaging anterior orbital structures such as trochlea,
levator palpebrae superiors, and supraorbital nerves. If
injury to the SOV or acute thrombosis happened before
J Radiol Sci June 2011 Vol.36 No.2
complete closure of the fistulas, retro-orbital hemorrhage
or acute deterioration of ocular symptoms may occur [8].
Direct percutaneous punctures through the superior orbital
fissure to the affected cavernous sinus or deep orbital puncture to the SOV have also been reported [8, 9]. However,
these methods used a very short distance of catheterization
in the venous structure and also carry the risk of retroorbital hematoma and other related injuries. These methods
are relatively technical-dependent and usually reserved as
the last choice of treatment.
From anatomic point of views, there are several tributary veins of the SOV that could be accessed [4, 10]. The use
of these veins differs by cases and depends on the venous
drainage of the cavernous sinus DAVF. Careful evaluation
of angiographies to determine the accessible vein is very
important. Cases of transfemoral catheterization through
the retromandibular vein, the superficial temporal vein,
and then the SOV has been reported [2, 11]. Frontal vein
direct puncture and catheterization into the SOV has been
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endovascular treatment of cavernous sinus DaVF
reported and has a favorable result [10]. Surgical exposure
of the facial vein at the base of the mandible bone has also
been used to reach the cavernous sinus [12].
In our case, transarterial embolization and transfemoral transvenous approaches had failed. After analysis
of the venous drainage of the fistulas, the left facial vein
was the major drainage vein and was clearly demonstrated,
especially in the AP projection of the contralateral carotid
angiographies. Because this segment of facial vein is usually
not easy to identify from the surface, we put two small lead
markers on the patient’s cheek as our puncture guideline.
Using simple venous access technique by an IC needle was
successfully done without much difficulty. In addition, this
method does not require surgical exposure of the SOV or
the facial vein, as described in the previous reports [5, 12].
Direct percutaneous facial vein puncture for treatment of cavernous sinus DAVF has its advantages. First,
shorter intravascular catheterization distance allows better
control to manipulate the microcatheter, as compared to
transfemoral approaches. The distance is also long enough
to provide good support of the microcatheter as compared
to the closer approaches such as direct puncture to deep
SOV or cavernous sinus. Second, if an unexpected occlusion of the approach vein occurs before complete closure of
the DAVF, collateral tributary veins including supraorbital
or superficial temporal vein, retromandibular vein, frontal
vein, and contralateral angular vein may prevent rapid deterioration of ocular symptoms [12].
In conclusion, direct percutaneous puncture of the
facial vein by using surface markers as the guideline to
approach the SOV can be an alternative method for transvenous embolization of cavernous sinus DAVF when other
approaches have failed. This technique is relatively simple
and safe which doesn’t required surgical exposure of the
vein. Careful evaluation of angioarchitectures is mandatory
to identify the accessible route for transvenous embolization. Contralateral digital subtracted arteriogram and
roadmap in AP projection are the best image references for
the direct percutaneous puncture of facial vein in such a
circumstance.
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J Radiol Sci June 2011 Vol.36 No.2