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Case Reports
. 2022 Jul 12;17(9):3312-3317.
doi: 10.1016/j.radcr.2022.06.043. eCollection 2022 Sep.

Transorbital hybrid approach for endovascular occlusion of indirect carotid-cavernous fistulas-Case report and systematic literature review

Bascarevic Vladimir  1   2 , Vukasinovic Ivan  3 , Nedeljkovic Zarko  1 , Nedeljkovic Aleksandra  1 , Milicevic Mihailo  1   2 , Jovanovic Nemanja  1 , Milic Marina  1   2 , Stanimirovic Aleksandar  1 , Scepanovic Vuk  1   2 , Grujicic Danica  1   2
Affiliations
Case Reports

Transorbital hybrid approach for endovascular occlusion of indirect carotid-cavernous fistulas-Case report and systematic literature review

Bascarevic Vladimir et al. Radiol Case Rep. .

Abstract

Carotid-cavernous fistulas (CCF) are vascular malformations characterized by an aberrant shunt between one or more sources of arterial inflow and the cavernous sinus (CS). They are subdivided into direct and indirect fistulas. This last one, called dural CCF involve dural fistulous connections between branches of the internal carotid artery or the external carotid artery. When conventional routes are not eligible, surgical exposure of the vein is the only access to the fistula. We present the case of a patient successfully treated for right sided dural CCF, by a hybrid approach. Furthermore, through a literature review, we analyze the possible risks and benefits associated with this approach.

Keywords: Dural carotid-cavernous fistula; Embolization; Hybrid approach; Superior ophthalmic vein cannulation.

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Figures

Fig 1
Fig. 1
(A) Contrast-enhanced magnetic resonance brain imaging reveals a proptosis (yellow arrow) and an enhancement of the right SOV (white arrow) (B) CT angiography revealed early enhancement of the right CS (yellow arrow) with dilated right SOV (white arrow).
Fig 2
Fig. 2
(A) DSA of the right internal carotid artery (ICA) in lateral projection showing dural arteries of the carotid siphon feeding the right cavernous sinus shunts (yellow arrow) and deeply located dilatated superior ophthalmic vein (SOV) (white arrow) (B) DSA of the left ICA in anteroposterior projection showing irrigation via small dural branches of the left siphon draining (yellow arrow) in the right CS and the right SOV (white arrow) (C) The lack of access to the inferior petrosal sinus from the catheter in the right jugular bulb (white arrow).
Fig 3
Fig. 3
Prior to the procedure, it was verified that the microcatheter Headway DUO is able to pass through the 17G (white) cannula. Headway DUO was previously coaxially inserted into 5-Fr diagnostic vertebral catheter for better support (white arrow).
Fig 4
Fig. 4
(A) DSA identification of the superior ophthalmic vein (SOV) at the tip of the hemostat plier (white arrow) (B) Transvenous microwire looping into the cavernous sinus (CS) through SOV (yellow arrow) (C) Microcatheter injection with opacification of CS and SOV, tip of the microcatheter positioned at the posterior part of CS (white arrow) (D) CS filled with coils and liquid embolic agent E.V.O.H. (Squid 12), resulting in complete obliteration of the fistula (yellow arrow) (E) Visualization of the right internal carotid artery (white arrow) with complete closure of the fistula.
Fig 5
Fig. 5
Procedure outcomes and recovery (A) Chemosis, proptosis and paresis of the right CN IV before embolization (white arrow) (B) Resolution of chemosis and proptosis 1 month after embolization (yellow arrow).
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