Cavernous sinus dural fistulae treated by transvenous approach through the facial vein: report of seven cases and review of the literature

Abstract

Background and purpose: Dural Carotid Cavernous Fistulas (CCFs) can be treated by transarterial and/or transvenous endovascular techniques. The venous route usually goes through the internal jugular vein (IJV) and the inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In case a thrombosed IPS, catheterization through the obstructed sinus is not always possible and a puncture of the superior ophthalmic vein (SOV) can be performed often after a surgical approach. We report our results in the endovascular transvenous treatment of dural CCFs through the facial vein (retrograde catheterization of the IJV, facial vein, angular vein, SOV, and cavernous sinus).

Methods: A retrospective study of seven patients with a dural CCF treated with transvenous embolization via the facial vein was performed. In five patients, the IPS was thrombosed. In one patient, the IPS was patent, but there was not communication between the cavernous sinus compartment in which the CCF shunts were located and the IPS itself. In the only patient with the CCF draining through permeable IPS, the transvenous route through the IPS permitted the occlusion of the posterior CCF shunts and a second session was performed through the facial vein in order to occlude the shunts of the anterior compartment of the cavernous sinus. The other six patients underwent one embolization session only.

Results: In all seven cases, it was possible to navigate through the tortuous junction of the angular vein and the SOV. In one patient with a thrombosed SOV, the venous procedure was interrupted because the catheterization through the occluded SOV failed. In the other six patients, after transvenous catheterization of the cavernous sinus via the facial vein, placement of coils resulted in complete occlusion of the dural CCF with clinical cure in four patients and improvement in two.

Conclusion: In the endovascular treatment of the dural CCFs, the transfemoral approach via the facial vein provides a valuable alternative to other transvenous routes. Catheterization of the cavernous sinus via the facial vein is usually successful. Although this technique requires caution, it allows a safe and effective treatment of these lesions.

Fig 1.

Dural AVF of the right cavernous sinus in a 45-year-old woman. A, Lateral view angiogram of the right common artery, obtained before embolization, shows a dural AVF. The inferior petrosal sinus is thrombosed at the level of its inferior portion. B, Oblique view angiogram of the internal carotid artery, obtained before embolization, shows a dural AVF with predominant venous drainage toward the SOV and facial vein (arrow). C, Anteroposterior view angiogram of the external carotid artery, obtained before embolization, shows a dural AVF with predominant venous drainage toward the SOV. D, Lateral view road map, obtained by injecting the internal carotid artery, shows intermediate steps of the retrograde catheterization through the facial vein up to the cavernous sinus. The tip of the microcatheter is in the angular vein. Facial vein (thick arrow), angular vein (short thin arrow), SOV inferior root (double arrows), SOV superior root (long thin arrow). E, Oblique view road map, obtained by injecting the external carotid artery, shows that the microcatheter (with the microguidewire) is in the angular vein before the SOV superior root, which is elongated and dilated. Facial vein (thick arrow), angular vein (short thin arrow), SOV inferior root (double arrows), SOV superior root (long thin arrow). F, Lateral view road map, obtained by injecting the internal carotid artery, shows intermediate steps of the retrograde catheterization through the facial vein up to the cavernous sinus. The microcatheter reaches the posterior part of the cavernous sinus, while the microguidewire is pushed up to the thrombosed inferior petrosal sinus. G, After positioning of coils within the cavernous sinus, lateral view angiogram of the right internal carotid artery shows complete occlusion of the dural fistula. H, After positioning of coils within the cavernous sinus, lateral view angiogram of the external carotid artery shows complete occlusion of the dural fistula.

Fig 2.

Schematic drawing of the venous system connecting the facial vein and the cavernous sinus. Facial vein (thick arrow), angular vein (short thin arrow), SOV inferior root (double arrows), SOV superior root (long thin arrow).