Cavernous Sinus Dural Arteriovenous Fistula: Treatment via the Transfemoral Transfacial Route

Cavernous sinus dural arteriovenous fistulas (dAVFs) are most frequently treated by a transvenous approach via the inferior petrosal sinus (IPS). However, in certain patients, the IPS is not amenable to navigation. In this technical video, we present the case of a patient with a cavernous sinus dAVF embolized by the transfemoral transfacial venous route on a failed attempt to catheterize the IPS. Preprocedural head and neck imaging was performed, documenting the facial vein draining to the internal jugular vein via the common facial vein on the side of the fistula. Embolization was accomplished without complications, with complete exclusion of the fistula. We suggest that treatment via the transfemoral transfacial venous pathway should be attempted and followed through whenever the IPS is not amenable to catheterization, on the basis of favorable preprocedural anatomy and the safety and efficacy demonstrated in several published case series.