Management of carotid-cavernous fistulas by surgery combined with interventional radiology

Abstract

Two cases of carotid-cavernous fistulas were successfully treated by standard interventional radiology techniques after otherwise inaccessible vessels were surgically exposed. In the first case, an internal carotid artery (ICA), which had previously been ligated as part of an attempted surgical "entrapment" procedure, was recanalized to permit passage of a detachable balloon catheter to the fistula, resulting in its obliteration. In the second case, an enlarged superior ophthalmic vein was exposed and isolated to facilitate retrograde catheterization of the cavernous sinus and obliteration of a dural fistula between the ICA and the cavernous sinus by steel Gianturco coils. The methods and complications of both procedures are discussed.

Endovascular Approaches to the Carotid Cavernous Sinus for Endovascular Treatment of Carotid Cavernous Fistulas and Hormone Sampling

“…Furtheremore, it may also cause palsy of the superior levator muscle and palpebral ptosis . The direct-puncture approach to the intraconal portion of the SOV has been reported in the literature 13,[16][17][18][19][20] (Fig 4D). It is particularly useful in cases with a SOV dilated only within the intraconal segment, with thrombosed branches of the SOV 16 17 , the posterior half of the SOV 18 , the superior orbital fissure 19 to the SOV usually results in difficulty in making an exact access and in preventing bleeding from the puncture point.…”

“…With deep-puncture (the posterior third of the SOV 17 , the posterior half of the SOV 18 , the superior orbital fissure 19 to the SOV) precise access and prevention of bleeding from the puncture point is usually difficult. Massive retro-orbital bleeding may occur and result in an untoward increase of orbital pressure 13 .…”

“…Direct exposure may damage the superior root of the fifth nerve resulting in numbness of the forehead 17 . Furthermore, it may also cause palsy of the superior levator muscle resulting in palpebral ptosis Direct-puncture approach to the intraconal portion of the SOV has been reported in the literature 13,[15][16][17][18][19][20] . This method is a useful in cases with a dilated SOV only within the intraconal segment, according to the thrombosed branches of the SOV 17 .…”

“…Various kinds of venous approaches have been reported: the inferior petrosal sinus (IPS) route was the first established and most commonly used [4][5][6] , especially for venous hormone sampling 2,3 . When the ophthalmic vein [7][8][9][10][11][12][13][14][15][16][17][18][19][20] , superior petrosal sinus (SPS) 21 and pterigoid plexus (PP) 22 are involved in venous drainages of CCFs, each venous channel may become an appropriate access route. …”

“…SOV, IOV approach [7][8][9][10][11][12][13][14][15][16][17][18][19][20] Approaches via direct puncture approach to the SOV and IOV and through the SOV from the dilated superficial temporal vein or division of external jugular vein are limited to CCF patients with comparative high flow drainages mainly inflowing into the SOV and/ or the inferior ophthalmic vein (IOV).…”