A venographic operational classification for transvenous embolization of dural carotid-cavernous fistula

It is hypothesized that a venographic-based operational classification of dural carotid-cavernous fistula (DCCF) will facilitate early selection of the optimal venous route and enhance the efficacy of transvenous catheterization and embolization of the cavernous sinus.

This was a retrospective study on 97 patients who presented with symptomatic DCCF. Definition of classification type 1: both the anterior and posterior compartments of the cavernous sinus were opacified, type 2: only the anterior compartment was opacified, type 3: only the posterior compartment was opacified. Subtype a: the facial vein (FV) draining the superior ophthalmic vein (SOV) was opacified, subtype b: only the inferior petrosal sinus (IPS) was opacified, subtype c: neither the FV nor the IPS were opacified, subtype d: both the FV and the IPS were opacified. The SOV route was recommended for subtype 1a and type 2. The IPS route was recommended for subtype 1b, 1c, 1d, and type 3. Success rates of catheterization by the recommended routes and non-recommended routes were calculated.

Number of DCCF lesions were 20 (1a), 28 (1b), 23 (1c), 26 (1d), 16 (2a), 10 (2c), 2 (3b). Of 145 attempted catheterization, 91 and 54 were performed with a recommended route and un-recommended route, respectively. Success rate for catheterization and embolization performed with the recommended route and un-recommended route was 71/91 (78%) and 20/54 (37%), respectively (Chi-Square test P = 0.0024).

Venographic operational classification is useful for guiding the selection of optimal venous route which enhances the efficacy of transvenous embolization of the DCCF.