Results of transvenous embolization of cavernous dural arteriovenous fistula: a single-center experience with emphasis on complications and management

Abstract

Background and purpose: To describe the results of transvenous embolizations of cavernous dural arteriovenous fistua (cDAVF) with an emphasis on identifying the incidence, characteristics, and management strategies associated with the complications of transvenous embolization of cDAVFs.

Methods: Fifty-six consecutive patients who were treated by transvenous embolization for cDAVFs were reviewed. The approach routes, angiographic results, complications, and clinical outcome were assessed.

Results: Retrograde inferior petrosal sinus (n = 36), transfacial vein (n = 7), transcontralateral intercavernous sinus (n = 4), and direct superior ophthalmic vein (n = 3) approaches were used. Angiographic results showed complete occlusion (n = 29), nearly complete occlusion (n = 13), and incomplete occlusion (n = 14). Complications associated with the procedures were cranial nerve palsy (n = 6), venous perforation (n = 3), and brain stem congestion (n = 2). The cranial nerve signs resolved with conservative treatment. Venous perforations were managed by coil embolizations at the site of the tear with no significant neurologic sequelae. One case of brain stem congestion resulted in hemiplegia after conservative treatment. The other case showed venous congestion as a result of rerouting of the shunted flow after venous embolization that was successfully managed by covered stent deployment for occlusion of the residual feeders. Clinical follow-up data were available in 46 patients. Complete resolution or improvement of symptoms was seen in 42 patients (91%).

Conclusions: Cavernous DAVFs may be effectively treated by transvenous embolization. However, the procedure can be associated with various complications, some of which can potentially result in significant morbidity. Prompt diagnosis of the complications with appropriate management strategies is mandatory for a safe procedure.

Fig 1.

A 60-year-old man presented with symptoms of decreased visual acuity, exophthalmos, and chemosis of the left eye of 1 month’s duration. A, Initial left ICA angiogram revealed an arteriovenous shunt at the left cavernous sinus with drainage into the superior ophthalmic and inferior ophthalmic veins. B, Transvenous coil embolization of the left cavernous sinus was performed via a left SOV approach, resulting in nearly complete occlusion of the target sinus with slow but stagnant flow in the anterior pontomesencephalic veins (arrows). C, Fluid-attenuated inversion recovery images of the patient after he developed mild dysarthria shows congestion of the brain stem. Bilateral graft stents were deployed for occlusion of the residual meningohypophyseal feeders. D, Poststent left ICA angiogram shows complete occlusion of the residual shunt.