Cavernous sinus dural arteriovenous fistula treated by facial vein direct puncture: Case report and review of the literature

Abstract

Introduction In case of cavernous sinus dural arteriovenous fistula (CSDAVF), transvenous embolization (TVE) of the cavernous sinus (CS) via the inferior petrosal sinus (IPS) is generally performed. However, various approach routes have been reported when the accessibility of the IPS is challenging. We herein report a case of CSDAVF treated by TVE with direct puncture of the facial vein. Case report A 70-year-old woman who suffered from tinnitus, chemosis, diplopia and bruit was referred to our hospital. Digital subtraction angiography (DSA) demonstrated CSDAVF. We initially attempted to perform TVE via the IPS route; however, we could not guide a catheter to the CS because of an anatomical difficulty. Then, we performed percutaneous direct puncture of the dilated facial vein, and successfully treated the patient. Conclusion When navigating microcatheter to the CS is difficult because of an anatomical difficulty of the IPS, direct puncture of the facial vein is a feasible route.

Keywords: Cavernous sinus dural arteriovenous fistula; facial vein approach; percutaneous direct puncture; transvenous embolization.

Figure 1.

((a), (b)) Right external carotid angiogram showed that feeders were collected in the intercavernous sinus (white arrow) and drained to the left cortical vein (*) and the left SOV (**). ((c), (d)) Left external carotid angiogram revealed that feeders were collected in the medial wall of the left CS (white arrows) and drained mainly to the left cortical vein (*). (e) The IPS and the left internal jugular vein were not observed by the angiogram. SOV: superior orbital vein; CS: cavernous sinus; IPS: inferior petrosal sinus.

Figure 2.

((a), (b)) The proximal side of the left FV was narrow. The right FV was connected to the EJV. ((c), (d)) The diameter of the FV was sufficiently large for puncture. The run was linear in the downward side of the orbita. (c) AP view. (d) Lateral view. FV: facial vein; EJV: external jugular vein; AP: antero-posterior.

Figure 3.

(a) The black line is an 18-G needle. (b) Intraoperative picture. A Y-connecter was connected to the outer tube directly, and was perfused by heparin.

Figure 4.

Intraoperative angiograms are shown. Before TVE, TAE were performed. The microcatheter was looped in the cavernous sinus, and also was indwelled at the orifice of the sphenoparietal sinus ((a) and (b)). After sinus packing ((c) and (d)), the fistula disappeared completely (e). TVE: transvenous embolization; TAE: transarterial embolization.