Percutaneous transorbital transvenous embolization of a cavernous sinus dural arteriovenous fistula via the superior orbital fissure—technical video

Abstract

Carotid-cavernous dural arteriovenous fistulas causing debilitating ocular symptoms and/or retrograde cortical venous drainage necessitate curative treatment, which is achieved by disrupting the proximal draining vein. Transvenous embolization of carotid-cavernous dural arteriovenous fistulas can be achieved through the superior or inferior petrosal sinuses, facial veins, or superior ophthalmic veins. ^{1, 2} However, if these approaches are not feasible, various percutaneous approaches have been described that use the skull base foramina to provide direct access to the cavernous sinus. ^{3, 4} Here we present the case of a 54-year-old male with carotid-cavernous dural arteriovenous fistulas with cortical venous drainage causing diplopia that was cured using a percutaneous transorbital approach. We discuss the alternative endovascular strategies for treating carotid-cavernous dural arteriovenous fistulas and why they were not chosen, the technical nuances of the transorbital approach as well as the pearls and pitfalls of this seldom used technique. A comprehensive understanding of the many approaches for treating carotid-cavernous dural arteriovenous fistulas is important for neurointerventionalists.