Transvenous approach via inferior petrosal sinus is one of the most widely used route for endovascular treatment of dural arteriovenous fistula (dAVF) around cavernous sinus or carotid-cavernous fistula (CCF). When it is not possible, however, direct access through superior ophthalmic vein (SOV) could be considered alternatively. A 72-year-old female admitted to our hospital presented unilateral orbital pain, exophthalmos, and 6th nerve palsy, which had been being aggravated during a month. Magnetic resonance imaging and conventional angiography revealed dAVF that originated from internal maxillary artery leaking into SOV. We attempted the conventional venous approach via femoral vein-external jugular vein and facial vein. However, we failed to proceed the microcatheter into the left SOV owing to its tortuous and stenotic point. We chose an alternative treatment strategy, surgical exposure of the SOV following linear incision on eyelid and direct cannulation. Two temporary clips (Yasargil mini curved) seized the SOV and FAST-CathTM for children (4 Fr, 8.5 cm) was inserted. We used a smaller sheath, which is shorter and softer than conventional endovascular catheter. It was beneficial in SOV puncture and catheter anchoring.
Dural arteriovenous fistula (dAVF) indicates the abnormal connection between the artery and vein in the dura and is known to comprise of 10% to 15% of arteriovenous malformations
The treatment of dAVF includes compressing the internal carotid artery, radiation therapy, surgical therapy, and endovascular therapy. Currently, endovascular therapy is the most preferred treatment modality due to its high success rate and safety, in which transvenous embolization is commonly being performed with the path via the internal jugular vein (IJV) and inferior petrosal sinus (IPS) being used most advantageously
However, due to the failure of transvenous approach through femoral vein, the author would like to brief a case of dAVF embolization through superior ophthalmic vein (SOV).
A 72-year-old female admitted to our hospital presented with diplopia after falling down a month ago and exophthalmos which was aggravated 2 weeks ago. The patient was being treated for diabetes and Parkinson’s disease and did not have any other specific disease history. During the time of admission, the patient showed visual blurring and diplopia with pain in the left eye in which a bruit could be auscultated. The patient’s eye examination performed in the ophthalmology department showed restriction in lateral gaze, exophthalmos, and subconjunctival hemorrhage with visual acuity test showing 0.4 in the right eye and 0.3 in the left eye, and intraocular pressure of 17mmHg in the right eye and 25 in the left.
Brain magnetic resonance imaging performed after admitting to our department presented protrusion of the SOV and dAVF in the left cavernous sinus. Additionally, digital subtraction angiography (DSA) was performed using femoral artery in which a dAVF with blood supplied from the terminal of the maxillary artery and draining to the SOV and facial vein was observed (
In order to treat the dAVF, embolization via the femoral vein, external jugular vein, and facial vein was attempted twice but the procedure failed as the microcatheter could not pass through the stenotic portion connecting the angular vein to the SOV (
After general anesthesia, the SOV was exposed through an incision in the left eyelid. Temporary clipping with Yasargil mini curved clip was done, pediatric FAST-CathTM (4 FR, 8.5 cm; St. Jude Medical, Minnetonka, MN, USA) inserted (
The dAVF is the abnormal vascular connection between the artery and vein arising from the dura, and is known to be common among the elderly, postmenopausal women with a history of hypertension, and secondary causes from trauma or surgery
Treatment modalities for dAVF includes blocking the blood flow by clot formation in the cavernous sinus by compressing the ipsilateral internal jugular artery, surgical treatment, and endovascular treatment, in which the current method of preference is the endovascular treatment
The endovascular treatment method could be classified according to the method of approach into the transarterial approach and the transvenous approach. The transarterial approach is known to be difficult for complete embolization as there are many dural arteries and small branches, and has a high recurrence rate
If access to the IPS in the transvenous approach is unavailable, another approach through the pterygoid plexus, angular vein, and facial vein exists but there is a difficulty in treatment due to vessel curvature or hypoplasia, and stenosis
However, the approach through the SOV has a high success rate compared to other approaches and a low rate of complications, therefore being considered an alternative approach to the access via IPS through the femoral vein. The nonexistence of valves and the straightness of the vessel pathway are also advantages of the endovascular procedure using the SOV
Various case reports of endovascular embolizations through the SOV have been reported (
Incision methods in the SOV approach consists of using the upper lid fold or incising under the eyebrow. There are studies suggesting that making an incision close to the superior orbit is favorable, and in our case, we determined the location of the SOV through angiography and performed skin incision by using the upper lid fold, which was the shortest route of access to the vein
In cases of dAVF treatment where endovascular procedures through conventional routes are not feasible, endovascular procedure through the SOV should be considered, and in order to increase success rates and reduce complications, the exact location and exposure of the SOV through angiography should be performed as well as using a catheter with a narrow diameter and temporary clip which could be valuable for the procedure such as in our case.
No potential conflict of interest relevant to this article was reported.
(A) Left superior ophthalmic vein observed in the T2 weighted image of brain magnetic resonance imaging. (B–D) Brain angiography showing dural arteriovenous fistula supplied by the left maxillary artery and draining to facial vein.
(A) Approach to superior ophthalmic vein (SOV) via left facial vein attempted but stenosis observed at connection portion between angular vein and SOV. (B) Attempt through stenotic portion and passage of micro guidewire but failure of microcatheter entry.
(A) Location of superior ophthalmic vein (SOV) by using needle during brain angiography. (B) Temporary clip (Yasargil mini curved clip) used in exposed SOV with insertion of pediatric FAST-CathTM (4 Fr, 8.5 cm; St. Jude Medical, Minnetonka, MN, USA).
Entry of microcathether to superior ophthalmic vein and embolization performed by using (A) pushable coils (TornadorTM 3×2 8 EA) and (B) detachable coils (axiom helix 2×6 2 EA, 2×4 1 EA), and obliteration of arteriovenous fistula confirmed.
Previous patient case report of arteriovenous fistula using transvenous approach
Studies | Age/Sex | Diagnosis | Approach | Microcatheter | Material | Occlusion | Anchoring |
---|---|---|---|---|---|---|---|
Ha et al., 2011 |
69/F | DAVF | SOV | Microcatheter (Prowler 18; Cordis, Miami Lakes, FL, USA) | Coil | Complete | |
Chalouhi et al., 2012 |
60/F | CCF | SOV | Echelon-10 microcatheter (ev3 Endovascular, Plymouth, MN, USA) | Onyx 18 | Complete | |
Tanaka et al., 2014 |
37/F | CCF | SOV | Excelsior 45° (Boston Scientific, Natick, MA, USA) | Coil | Incomplete | |
Thiex et al., 2014 |
66/F | CCF | FV | 4 Fr short access sheath (Cordis) | Coil | Complete | |
Alexandre et al., 2017 |
62/M | DAVF | FV | Echelon-10 microcatheter (ev3 Endovascular) | Coil | Complete | |
This study, 2017 | 71/F | DAVF | SOV | FAST-CathTM (4Fr, 8.5 cm; St. Jude Medical, Minnetonka, MN, USA) | Coil | Complete | Temporary clip (Yasargil mini curved clip) |
F: female; M: male; dAVF: dural arteriovenous fistula; CCF: carotid-cavernous fistula; SOV: superior ophthalmic vein; FV: facial vein; Fr: French.