Superficial middle temporal vein as a pivotal route to embolize dural carotid-cavernous fistulas

Dural carotid-cavernous fistulas (DCCF) are located in the cavernous sinus wall involving the arterial feeders from the external and internal carotid arteries. The venous route usually passes through the internal jugular vein and inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In cases of a thrombosed IPS, catheterization is not always possible because of the obstruction. Here, we report eight cases of DCCF treated with endovascular transvenous embolization via the superficial middle temporal vein (SMTV). A retrospective study involving eight patients with DCCF treated with transvenous embolization via SMTV was performed. In six patients, IPS was thrombosed. In one patient, IPS was patent, but we could not catheterize the internal jugular vein. In the other patient, because of the compartmentalization of the cavernous sinus, we could not access the anterior part of the cavernous sinus via IPS. Therefore, we performed the embolization via SMTV to occlude the shunts of the anterior part of the cavernous sinus. In all eight cases, navigating through the tortuous junction of the angular vein and superior ophthalmic vein (SOV) was possible. After transvenous catheterization of the cavernous sinus via SMTV, placement of coils resulted in complete occlusion of DCCF with clinical improvement in all eight patients. In the endovascular treatment of DCCF, the transfemoral approach via SMTV provides a pivotal route alternative to other transvenous routes. In patients with dilated SOV, catheterization of the cavernous sinus via SMTV is usually successful.