Transvenous Embolization of Cavernous and Paracavernous Dural Arteriovenous Fistula through the Facial Vein: Report of 12 Cases

Abstract

Purpose: The aim of this study was to evaluate the feasibility and safety of the transfacial venous embolization of cavernous or paracavernous dural arteriovenous fistula (DAVF) in which approach via inferior petrosal sinus (IPS) was not feasible.

Materials and methods: We identified the cases of transfacial venous embolization of cavernous sinus (CS) or adjacent dural sinuses from the neurointerventional database of three hospitals. The causes and clinical and angiographic outcomes of transfacial venous embolization were retrospectively evaluated.

Results: Twelve patients with CS (n = 11) or lesser wing of sphenoid sinus (LWSS, n = 1) DAVF were attempted to treat by transvenous embolization via ipsilateral (n = 10) or contralateral (n = 2) facial vein. Trans-IPS access to the target lesion was impossible due to chronic occlusion (n = 11) or acute angulation adjacent the target lesion (n = 1). In all twelve cases, it was possible to navigate through facial vein, angular vein, superior ophthalmic vein, and then CS. It was also possible to further navigation to contralateral CS through intercavernous sinus in two cases, and laterally into LWSS in one case. Post-treatment control angiography revealed complete occlusion of the DAVF in eleven cases and partial occlusion in one patient, resulting in complete resolution of presenting symptom in eight and gradually clinical improvement in four patients. There was no treatment-related complication during or after the procedure.

Conclusion: In the cavernous or paracavernous DAVF in which trans-IPS approach is not feasible, the facial vein seems to be safe and effective alternative route for transvenous embolization.

Keywords: Arteriovenous fistula; Cavernous sinus; Endovascular; Facial vein.

Fig. 1

Antero-posterior (A) and lateral (B) view of right ECA angiography show DAVF involving CS with arterial feeder from ECA and venous drainage to left SOV (large arrow), right sphenoparietal sinus and superficial middle cerebral vein through intercavernous sinus. (C, D) Through left facial vein (small arrows in figure A and B), the microwire was placed in right CS beyond the intercavernous sinus. (E) Coil embolization was performed for the shunt lesion using detachable and pushable fibered coils. (F) After the procedure, antero-posterior view of angiography selected right common carotid artery shows complete occlusion of the shunt.

Fig. 2

Lateral view (A) and three-dimensional reconstruction image (B) of left ECA angiography showed DAVF with shunt flow into LWSS (arrows) connected with CS. The embolization for the lesion via arterial approach was performed using detachable and pushable fibered coils. (C) Follow-up angiography after 3 months showed recanalized shunt at the LWSS and venous drainage mainly into the SOV via the CS. The microcatheter was placed in the left IPS by microwire, and the left CS was selected. However, it could not be further advanced due to acute angle at the connection site (small arrow in figure D) between the LWSS and CS. (E) The microcatheter was placed in the left FV and SOV, and then it could be placed at the LWSS (through large arrow pathway in figure D). (F) The remnant shunt was complete occluded by coils.