Transvenous n-butyl-cyanoacrylate infusion for complex dural carotid cavernous fistulas: technical considerations and clinical outcome

Abstract

Background and purpose: Endovascular transvenous embolization has been advocated as the treatment technique for dural carotid cavernous fistulas (dCCFs). Most centers use platinum coils primarily. The purpose of this study was to evaluate the technical aspects, efficacy, and safety of transvenous n-butyl cyanoacrylate (n-BCA) infusion in dCCFs as a primary alternative or adjunct to coil embolization.

Methods: We retrospectively evaluated 14 patients with dCCFs who were treated at this institution from 1999 to 2004 by using n-BCA infusion alone or in combination with coils. The efficacy of treatment and safety aspects were studied in dCCFs of Barrow type B (4/14), C (2/14), and D (8/14). Six patients were treated with transvenous n-BCA infusion alone in the cavernous sinus, 7 with a combination of transvenous n-BCA and coil embolization, and one with transvenous n-BCA combined with transarterial polyvinyl alcohol (PVA)-particle embolization of the feeding arteries.

Results: An angiographic obliteration and clinical cure was achieved in all patients. Technical complications were nonsymptomatic and included spillage of an n-BCA droplet into a middle cerebral artery branch retrograde through the arteriovenous fistulas in one patient and perforation of the inferior petrosal sinus during microcatheter placement in another. A third patient developed temporary palsy of the sixth cranial nerve a few days after the treatment.

Conclusion: In this small series, the use of n-BCA either alone or in conjunction with detachable coils was a safe and effective technique for the treatment of symptomatic patients presenting with complex dCCFs.

Fig 1.

Ninety-one-year-old woman (case 10 [Table 1]), 2 months after radiation therapy for nasopharyngeal carcinoma develops a slowly progressive right orbital swelling, chemosis, proptosis, and ophthalmoplegia. Angiogram shows a CCF with mixed dural artery supply via both ECA (type C, ref. 2). There is a retrograde venous drainage via the right ophthalmic vein and right cerebellar cortical veins. A transvenous n-BCA embolization combined with coils was carried out with successful dural CCF obliteration and complete clinical recovery. A, Right lateral ECA angiogram shows incomplete filling of the CS (arrowheads) and SOV (straight arrow). Discrete retrograde filling of the congested anterior cerebellar vein is noted (double arrows). Note there is no filling of the IPS. B, Placement of a 5F guide catheter over a wire through the obliterated IPS into the posterior-lateral segment of the CS. C, Right lateral CS venogram shows a proximal stenosis of the congested SOV (arrow) as source for the clinical symptoms and filling of cerebellar cortical veins (arrowheads) via proximal superior petrosal vein (double arrow). Note the guide catheter is occlusive within the IPS. D, Lateral radiograph shows several coils placed in the CS for flow reduction and to protect acrylate spillage into SOV and anterior cerebellar veins. E, Lateral radiograph shows coils and n-BCA-Ethiodol cast of the entire CS segment depicted in panels A and C, proximal SOV (arrow), and the superior petrosal vein (double arrow). F and G, Early- and late-phase right lateral CCA angiograms show CCF obliteration.

Fig 2.

Eighty-seven-year-old woman (case 4, Table 1) presented with progressive ophthalmoplegia, decreased visual acuity, and chemosis. Angiogram shows a CCF with bilateral mixed dural artery supply both via the external and internal carotid arteries (type D, ref. 2), congestion of both cavernous segments with retrograde flow in both SOV. A transvenous embolization was carried out by using n-BCA with complete CCF obliteration and cure of symptoms. A–D, Early- and late-phase right lateral and frontal ICA angiograms show slow contrast filling (A, thin double arrow) through dural branches of the ICA (A, arrow) including capsular arteries of McConnell at the floor of sella turcica. Retrograde filling of the SOV (arrowhead) with origin stenosis (B and C, double arrows). Note delayed contrast washout (B–D, arrows) of the CS bilaterally. E and F, Frontal and lateral radiographs show the microcatheter in the left cavernous segment (arrow) before n-BCA infusion. Microcatheter was navigated through the SOV (double arrow) and the anterior intercavernous connection (arrowhead). G and H, Frontal and lateral radiograph show the n-BCA-Ethiodol cast within the CS bilaterally. Some embolic material spillage is seen in the right proximal SOV through the stenotic segment (arrow). Note the radiolucent structures within the glue cast represent the internal carotid arteries. I–L, Left lateral early and late phase ICA angiograms (I and J) and right and left frontal angiogram show CCF obliteration. Note artifacts related to the embolic material (arrows).

Fig 3.

Forty-four-year-old man (case 14 [Table 1]) develops a slowly progressive bilateral chemosis and proptosis. A transvenous n-BCA embolization combined with platinum coils was carried out with successful CCF obliteration and clinical recovery. A–J, Early and late right ICA lateral (A and B), right ECA frontal (C and D), left ICA frontal and lateral (E–I), and left ECA frontal (J) angiograms show a CCF with mixed bilateral (left > right) dural artery supply via both ECA and ICA (A, B, E, F, G, arrows, Type D-2, ref. 2). There is an early venous drainage via both IPS (D, arrows; I, double arrow), both SOVs (right > left; I, small arrowheads), and the right sphenoparietal vein (F, H, I, arrowheads). Marked dilation of the right CS segment as compared with the left (F and H, small arrows) with prominent “radiolucent” ICA boundaries (F and J). K and L, Superselective catheterization of the left CS segment through the right IPS and microcatheter tip placement into the anterior-medial segment (arrow). The microcatheter injection shows retrograde filling of both congested SOVs (small arrowhead and small arrows) and the right sphenoparietal vein (arrowheads). (Continued)M, The microcatheter tip is placed further into the left common ophthalmic vein (arrow). N, Placement of platinum coils into the common ophthalmic vein (arrow) and cavernous sinus to reduce flow in CS and protect acrylate spillage. O, Microcatheter control angiography shows filling of the cavernous sinus and the common ophthalmic vein (arrow), but sparse filling of SOV. P and Q, Acrylate infusion under plain roadmap with casting of the cavernous sinus. Note n-BCA is contained within the coil mass, no spillage into SOV (arrows). R–X, Bilateral ICA and ECA early and late control angiography shows CCF obliteration with antegrade filling of the sphenoparietal vein and slow outflow (V, arrowheads). (Continued) Y and Z, Chemosis and conjunctivitis before treatment. Near-complete resolution 2 weeks after CCF obliteration.

Fig 3.

Forty-four-year-old man (case 14 [Table 1]) develops a slowly progressive bilateral chemosis and proptosis. A transvenous n-BCA embolization combined with platinum coils was carried out with successful CCF obliteration and clinical recovery. A–J, Early and late right ICA lateral (A and B), right ECA frontal (C and D), left ICA frontal and lateral (E–I), and left ECA frontal (J) angiograms show a CCF with mixed bilateral (left > right) dural artery supply via both ECA and ICA (A, B, E, F, G, arrows, Type D-2, ref. 2). There is an early venous drainage via both IPS (D, arrows; I, double arrow), both SOVs (right > left; I, small arrowheads), and the right sphenoparietal vein (F, H, I, arrowheads). Marked dilation of the right CS segment as compared with the left (F and H, small arrows) with prominent “radiolucent” ICA boundaries (F and J). K and L, Superselective catheterization of the left CS segment through the right IPS and microcatheter tip placement into the anterior-medial segment (arrow). The microcatheter injection shows retrograde filling of both congested SOVs (small arrowhead and small arrows) and the right sphenoparietal vein (arrowheads). (Continued)M, The microcatheter tip is placed further into the left common ophthalmic vein (arrow). N, Placement of platinum coils into the common ophthalmic vein (arrow) and cavernous sinus to reduce flow in CS and protect acrylate spillage. O, Microcatheter control angiography shows filling of the cavernous sinus and the common ophthalmic vein (arrow), but sparse filling of SOV. P and Q, Acrylate infusion under plain roadmap with casting of the cavernous sinus. Note n-BCA is contained within the coil mass, no spillage into SOV (arrows). R–X, Bilateral ICA and ECA early and late control angiography shows CCF obliteration with antegrade filling of the sphenoparietal vein and slow outflow (V, arrowheads). (Continued) Y and Z, Chemosis and conjunctivitis before treatment. Near-complete resolution 2 weeks after CCF obliteration.

Fig 3.

Forty-four-year-old man (case 14 [Table 1]) develops a slowly progressive bilateral chemosis and proptosis. A transvenous n-BCA embolization combined with platinum coils was carried out with successful CCF obliteration and clinical recovery. A–J, Early and late right ICA lateral (A and B), right ECA frontal (C and D), left ICA frontal and lateral (E–I), and left ECA frontal (J) angiograms show a CCF with mixed bilateral (left > right) dural artery supply via both ECA and ICA (A, B, E, F, G, arrows, Type D-2, ref. 2). There is an early venous drainage via both IPS (D, arrows; I, double arrow), both SOVs (right > left; I, small arrowheads), and the right sphenoparietal vein (F, H, I, arrowheads). Marked dilation of the right CS segment as compared with the left (F and H, small arrows) with prominent “radiolucent” ICA boundaries (F and J). K and L, Superselective catheterization of the left CS segment through the right IPS and microcatheter tip placement into the anterior-medial segment (arrow). The microcatheter injection shows retrograde filling of both congested SOVs (small arrowhead and small arrows) and the right sphenoparietal vein (arrowheads). (Continued)M, The microcatheter tip is placed further into the left common ophthalmic vein (arrow). N, Placement of platinum coils into the common ophthalmic vein (arrow) and cavernous sinus to reduce flow in CS and protect acrylate spillage. O, Microcatheter control angiography shows filling of the cavernous sinus and the common ophthalmic vein (arrow), but sparse filling of SOV. P and Q, Acrylate infusion under plain roadmap with casting of the cavernous sinus. Note n-BCA is contained within the coil mass, no spillage into SOV (arrows). R–X, Bilateral ICA and ECA early and late control angiography shows CCF obliteration with antegrade filling of the sphenoparietal vein and slow outflow (V, arrowheads). (Continued) Y and Z, Chemosis and conjunctivitis before treatment. Near-complete resolution 2 weeks after CCF obliteration.