J Korean Neurosurg Soc.  2022 Sep;65(5):688-696. 10.3340/jkns.2021.0250.

Use of a Rigid-Tipped Microguidewire for the Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas with an Occluded Inferior Petrosal Sinus

• Deniwar MA
• Kwon B
• Song Y
• Park JC
• Lee DH

• KMID: 2533031
• DOI: http://doi.org/10.3340/jkns.2021.0250

Abstract

Objective
: Transvenous embolization (TVE) via an occluded inferior petrosal sinus (IPS) in a cavernous sinus dural arteriovenous fistula (CSDAVF) is challenging, often requiring navigation of a microcatheter through resistive obstacles between the occluded IPS and shunted pouch (SP), although the reopening technique was successfully performed. We report five cases of successful access to the cavernous sinus (CS) or SP using the rigid-tipped microguidewire such as chronic total occlusion (CTO) wire aiming to share our initial experience with this wire.
Methods
: In this retrospective study, four patients with CSDAVF underwent five procedures using the CTO wire puncture during transfemoral transvenous coil embolization. Puncture success, shunt occlusion, and complications including any hemorrhage and cranial nerve palsy were evaluated.
Results
: Despite successful access through the occluded IPS, further entry into the target area using neurointerventional devices was impossible due to a short-segment stricture before the CS (three cases) and a membranous barrier within the CS (two cases). However, puncturing these structures using the rigid-tipped microguidewire was successful in all cases. We could advance the microcatheter over the rigid-tipped microguidewire for the navigation to the SP and achieved complete occlusion of the SP without complications.
Conclusion
: The use of the rigid-tipped microguidewire in the TVE via the occluded IPS of the CSDAVF would be feasible and safe.

Keyword

Cavernous sinus; Central nervous system vascular malformations; Dural arteriovenous fistula; Embolization, therapeutic

Figure

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  Fig. 1. Showing illustration of the case (case 4). The patient complained of the right conjunctival injection and sixth cranial nerve palsy. Right cavernous sinus dural arteriovenous fistula (CSDAVF) was demonstrated in both frontal (A and B) and lateral views (C and D) of the right external carotid artery (ECA) angiography and 3D rotational angiography. The 3D rotational angiography of the right ECA was contaminated by the ipsilateral ICA opacification. Ipsilateral superior petrosal sinus, inferior petrosal sinus, and intercavernous sinus were occluded. Venous drainage via a mainly ipsilateral superior ophthalmic vein and partly inferior ophthalmic vein were noted. The white solid arrow in each panel (A-D) indicated the shunted pouch (SP). Multiple dural feeders fed the SP from the bilateral internal carotid artery and ECA, such as a middle meningeal artery, accessory meningeal artery, ascending pharyngeal artery, artery of foramen Rotundum, and meningohypophyseal trunk.

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  Fig. 2. Showing intraoperative procedures (case 4). A : A 4-F diagnostic catheter was placed at the right proximal external carotid artery (ECA) for the arteriographic roadmap. A 6-F guide catheter was introduced through the right internal jugular vein. The 6-F guide catheter and another 4-F diagnostic catheter were used by means of the coaxial technique. To reinforce the 0.035-in guidewire, the 6-F guide catheter was inserted as close as possible to the right inferior petrosal sinus (IPS) orifice. The 4-F diagnostic catheter was also inserted into the distal part of the right IPS. Performing the frontier-wire technique, arteriographic and venographic roadmaps were acquired simultaneously with the presence of the 0.035-in guidewire. The microcatheter was successfully advanced with the guidance of the white footprint of the guidewire (white arrows). The microcatheter tip seemed to be in the shunted pouch (SP) (white arrowheads). B : Control angiogram, the microcatheter tip was in the isolated posterior aspect of the right cavernous sinus (CS) (white arrow). The membranous barrier could not be overcome by the neurointerventional microguidewires or 0.035-in guidewire. C : Under the biplane right ECA roadmaps, the direction of the microcatheter tip was controlled precisely using the neurointerventional microguidewire. With the removal of the neurointerventional microguidewire, the rigid-tipped microguidewire was introduced gently and then inserted only 1 mm further than the microcatheter tip (white arrows). Holding firmly the rigid-tipped microguidewire, the microcatheter could be advanced beyond the obstacle under the guidance of the rigid-tipped microguidewire. D : After removing the rigid-tipped microguidewire, control angiogram showed that the microcatheter tip was in the SP (white arrowhead). E : The microcatheter was able to navigate the CS using the microguidewire. Subsequent coil embolization of both the entry of the venous drainage and SP was done. The white arrow indicated the coil mass packed in the SP. In the final right ECA arteriography, the cavernous sinus dural arteriovenous fistula was obliterated and no residual flow.

Reference

References

1. Agid R, Willinsky RA, Haw C, Souza MP, Vanek IJ, TerBrugge KG. Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches. Neuroradiology. 46:156–160. 2004.

2. Benndorf G, Bender A, Lehmann R, Lanksch W. Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature. Surg Neurol. 54:42–54. 2000.

3. Brenna CTA, Priola SM, Pasarikovski CR, Ku JC, Daigle P, Gill HS, et al. Surgical sparing and pairing endovascular interventions for carotid-cavernous fistula: case series and review of the literature. World Neurosurg. 140:18–25. 2020.

4. Cheng KM, Chan CM, Cheung YL. Transvenous embolisation of dural carotid-cavernous fistulas by multiple venous routes: a series of 27 cases. Acta Neurochir (Wien). 145:17–29. 2003.

5. Cho YD, Rhim JK, Yoo DH, Kang HS, Kim JE, Cho WS, et al. Transvenous microguidewire looping technique for breach of ipsilateral inferior petrosal sinus occlusions en route to cavernous sinus dural arteriovenous fistulas. Interv Neuroradiol. 22:590–595. 2016.

6. Deniwar MA, Ambekar S, Elhammady MS. Multimodal management of a complex indirect carotid cavernous fistula. Neurol India. 63:606–607. 2015.

7. Ducruet AF, Albuquerque FC, Crowley RW, McDougall CG. The evolution of endovascular treatment of carotid cavernous fistulas: a single-center experience. World Neurosurg. 80:538–548. 2013.

8. Fu FW, Rao J, Zheng YY, Song L, Chen W, Zhou QH, et al. Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by transverse sinus thrombosis: a case report and review of literature. Medicine (Baltimore). 96:e7374. 2017.

9. Gemmete JJ, Ansari SA, Gandhi DM. Endovascular techniques for treatment of carotid-cavernous fistula. J Neuroophthalmol. 29:62–71. 2009.

10. Graeb DA, Dolman CL. Radiological and pathological aspects of dural arteriovenous fistulas. Case report. J Neurosurg. 64:962–967. 1986.

11. Hou K, Li G, Luan T, Xu K, Yu J. Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations. Int J Med Sci. 17:1121–1130. 2020.

12. Jia ZY, Song YS, Sheen JJ, Kim JG, Lee DH, Suh DC. Cannulation of occluded inferior petrosal sinuses for the transvenous embolization of cavernous sinus dural arteriovenous fistulas: usefulness of a frontier-wire probing technique. AJNR Am J Neuroradiol. 39:2301–2306. 2018.

13. Kim DJ, Kim DI, Suh SH, Kim J, Lee SK, Kim EY, et al. Results of transvenous embolization of cavernous dural arteriovenous fistula: a single-center experience with emphasis on complications and management. AJNR Am J Neuroradiol. 27:2078–2082. 2006.

14. Kiyosue H, Tanoue S, Hori Y, Hongo N, Mori H. Shunted pouches of cavernous sinus dural AVFs: evaluation by 3D rotational angiography. Neuroradiology. 57:283–290. 2015.

15. Kohyama S, Kaji T, Tokumaru AM, Kusano S, Ishihara S, Shima K. Transfemoral superior ophthalmic vein approach via the facial vein for the treatment of carotid-cavernous fistulas--two case reports. Neurol Med Chir (Tokyo). 42:18–22. 2002.

16. Lekkhong E, pongpech S, Ter Brugge K, Jiarakongmun P, Willinsky R, Geibprasert S, et al. Transvenous embolization of intracranial dural arteriovenous shunts through occluded venous segments: experience in 51 patients. AJNR Am J Neuroradiol. 32:1738–1744. 2011.

17. Luo CB, Chang FC, Teng MM, Lin CJ, Wang AG, Ting TW. Aggressive cavernous sinus dural arteriovenous fistula: angioarchitecture analysis and embolization by various approaches. J Chin Med Assoc. 79:152–158. 2016.

18. Mishra S. Language of CTO interventions - focus on hardware. Indian Heart J. 68:450–463. 2016.

19. Mishra S. Unraveling the mystique of CTO interventions: tips and techniques of using hardware to achieve success. Indian Heart J. 69:266–276. 2017.

20. Miyachi S, Izumi T, Matsubara N, Naito T, Haraguchi K, Wakabayashi T. Mechanism of the formation of dural arteriovenous fistula: the role of the emissary vein. Interv Neuroradiol. 17:195–202. 2011.

21. Ng PP, Halbach VV, Quinn R, Balousek P, Caragine LP, Dowd CF, et al. Endovascular treatment for dural arteriovenous fistulae of the superior petrosal sinus. Neurosurgery. 53:25–33. 2003.

22. Rhim JK, Cho YD, Park JJ, Jeon JP, Kang HS, Kim JE, et al. Endovascular treatment of cavernous sinus dural arteriovenous fistula with ipsilateral inferior petrosal sinus occlusion: a single-center experience. Neurosurgery. 77:192–199. 2015.

23. Sato M, Izumi T, Matsubara N, Nishihori M, Miyachi S, Wakabayashi T. Evaluation for shunted pouches of cavernous sinus dural arteriovenous fistula and the treatment outcome of transvenous embolization. Interv Neuroradiol. 24:189–196. 2018.

24. Satow T. Endovascular treatment of cavernous sinus dural arteriovenous fistulae: review of the literature and current status. J Neurointerv Surg. 14:572–582. 2020.

25. Suh DC, Lee JH, Kim SJ, Chung SJ, Choi CG, Kim HJ, et al. New concept in cavernous sinus dural arteriovenous fistula: correlation with presenting symptom and venous drainage patterns. Stroke. 36:1134–1139. 2015.

26. Sur S, Menaker SA, Alvarez C, Chen S, Shah SS, Peterson EC, et al. Multimodal management of carotid-cavernous fistulas. World Neurosurg. 133:e796–e803. 2020.

27. Tang CL, Liao CH, Chen WH, Shen SC, Lee CH, Lee HT, et al. Endoscope-assisted transsphenoidal puncture of the cavernous sinus for embolization of carotid-cavernous fistula in a neurosurgical hybrid operating suite. J Neurosurg. 127:327–331. 2017.

28. Yamauchi S, Nishio A, Takahashi Y, Kondo K, Kawakami T, Terakawa Y, et al. An innovative technique for detecting the caudal end of occluded inferior petrosal sinus in cavernous arteriovenous fistula using intravascular ultrasonography--technical note. Neuroradiology. 57:799–804. 2015.