Transorbital embolization of cavernous sinus dural arterio-venous malformations with surgical exposure and catheterization of the superior ophthalmic vein

Abstract

Purpose Cavernous sinus dural arterio-venous malformations (dAVF) represent a pathologic connection between branches of the internal and/or external carotid artery and the cavernous sinus. Standard endovascular approaches for dAVF treatment are transvenous embolization through the inferior petrosal sinus or the facial vein and transarterial embolization. These approaches are not always successful or feasible, and alternative techniques are required. Here, we present a case series of a minimally invasive transorbital approach with surgical exposure and catheterization of the superior ophthalmic vein for transvenous fistula coiling. Methods 14 patients with dAVFs (Barrow Type B to D) that were treated at a tertiary care medical center over a period of 13 years were included in the study. Patients with persisting dAVF associated symptoms were selected for this approach when conventional endovascular interventions were not successful or not feasible. The surgical procedure was performed under general anaesthesia. Results A successful transorbital approach was performed in all 14 cases. In 12 of 14 patients a catheter assisted successful embolization of the fistula was performed using platinum coils with no relevant residual fistula flow. In two cases, a spontaneous thrombosis of the fistula during the surgical procedure required no further embolization. No postoperative therapy-associated complications were observed. Conclusion The described approach is an effective method to embolize dAVFs in selected cases when catheter assisted transvenous and/or transarterial embolization is not successful or not feasible. In this case series we demonstrate an excellent success rate with no therapy-associated major complications.

Direct Transorbital Approach for Treatment of Carotid Cavernous Fistula: An Illustrative Case Series

“…Direct transorbital puncture to assess the fistula can be used when vascular architecture precludes arterial or venous approaches, with access most commonly from the superior orbital vein (SOV) or inferior orbital vein (IOV). This case series represents one of the largest descriptions of the direct transorbital approach [4][5][6][7][8][9][10][11] and includes case descriptions of all 4 CCF types and their management.…”