Embolization of dural carotid-cavernous fistulas via the thrombosed superior ophthalmic vein

To present the authors' experience treating dural carotid-cavernous sinus fistulas (CCF) with retrograde embolization via the thrombosed superior ophthalmic vein (SOV).

The medical records of 4 patients with dural CCFs treated via the thrombosed SOV were reviewed. All procedures were performed unilaterally in the interventional radiology unit with the administration of general anesthesia. The SOV was exposed via an eyelid crease incision, and then an angiocatheter was inserted in the vein and advanced through the segment with thrombosis to the cavernous sinus, where embolizing agents were deposited. After the procedure, the patients were followed up and evaluated clinically.

Three patients had unilateral CCFs, and 1 had a bilateral CCF (3 women and 1 man; age range, 58-68 years). The CCFs were Barrow type B (n=2) and Barrow type D (n=2). All patients had severe venous congestive orbital symptoms, chorioretinopathy, increased intraocular pressure, and visual loss. In all cases, the SOV appeared as a pale, thin, tortuous vessel adherent to the surrounding tissues during the surgical procedure. In 3 patients, the cavernous sinus was successfully embolized, and all symptoms were completely resolved without recurrence during follow up (3, 15, and 24 months). In the patient in whom the SOV could not be catheterized, the symptoms regressed slowly, but visual acuity remained unchanged during follow up (64 months).

Dural CCFs can be successfully treated through the SOV, even when the vein is thrombosed. Identification and catheterization of the thrombosed SOV may be difficult because of the tiny and fibrotic structure of the vein.