Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

Abstract

A cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication involving the dura mater within or near the CS wall. The dural arteries from the internal carotid artery and external carotid artery supply the CS-DAVF, and the superior ophthalmic vein (SOV) and inferior petrous sinus (IPS) are frequent venous drainers. In CS-DAVF cases, high-risk lesions require treatment. Endovascular treatment (EVT) has been the first-line option for CS-DAVFs. To our knowledge, a review of the EVT of CS-DAVFs is lacking. Therefore, in this paper, we review the available literature on this issue. In addition, some illustrative cases are also provided to more concisely expound the EVT of CS-DAVFs. According to the recent literature, transvenous embolization via the IPS is considered the most effective method for EVT of CS-DAVFs. In addition, the transorbital approach is another reasonable choice. Other venous approaches can also be tried. Because of the low cure rate, transarterial embolization for CS-DAVFs is limited to only highly selected patients. In the EVT of CS-DAVFs, various agents have been used, including coil, Onyx, and n-butyl cyanoacrylate, with coil being the preferred one. In addition, when EVT cannot obliterate the CS-DAVF, stereotactic radiotherapy may be considered. In general, despite various complications, EVT is a feasible and effective method to manage CS-DAVFs by way of various access routes and can yield a good prognosis.

Is the Middle Meningeal Artery the Optimal Path for Dural Arteriovenous Fistula Embolization?

“…The current treatment is EVT, which can involve transarterial and transvenous approaches (6). Although the transvenous approach is an effective method for treating some DAVFs, such as EVT via the cavernous sinus and certain TSSs, the transarterial approach remains the primary approach for treating most DAVFs (7).…”

Endovascular Treatment of Falcine Sinus Dural Arteriovenous Fistula

“…For DAVFs in the falcine sinus, similar to DAVFs located elsewhere, although various treatment options are available, EVT is still the most prevalent method. In addition, transarterial access is favored, unlike for DAVFs in the cavernous sinus, which allow the possibility of venous access for EVT [1].…”

Dural carotid-cavernous fistulas: our experience with endovascular management

“…The principle of treatment in any dural fistula is closure of the fistulous connection as well as the immediate draining veins close to the fistula. Since the feeders in cases of indirect CCF are small calibre meningeal arteries, mostly it is not possible to occlude the venous drainage along with the fistulous connection while performing embolization through the arterial route [13]. The delivery of embolization materials at the site of fistula and into the immediate draining vein is best achieved through transvenous access in dural type CCF.…”

“…Major alternative route targets the superior ophthalmic vein and its drainage territory into facial vein. USG-guided percutaneous puncture of the facial vein, direct puncture of ophthalmic vein with or without surgical exposure of the same, and even direct cavernous sinus puncture based on anatomic landmarks and with certain manoeuvres are described in literature [5,[13][14][15][16][17][18]. Cases are reported in literature where the interventionists have successfully cannulated the cavernous sinus through unconventional routes like via superior petrosal sinus or basal venous plexus and inferior petro-clival veins to embolize the dural CCF [19,20].…”

“…Trans-arterial access is taken when no suitable venous route is available and necessitates super-selective cannulation and embolization of ECA branches supplying the CCF [3,7,13]. Since the ICA branches to the fistula are usually too small to be selectively cannulated and there is also risk of migration of embolizing agents into the critical vessels supplying intracranial brain parenchyma, they are generally never embolized through arterial route.…”