J Cerebrovasc Endovasc Neurosurg.  2023 Sep;25(3):245-252. 10.7461/jcen.2023.E2022.10.005.

Superior ophthalmic approach in carotid-cavernous fistula: current concepts in indications, surgical techniques, and case reviews

• Park J

• KMID: 2546160
• DOI: http://doi.org/10.7461/jcen.2023.E2022.10.005

Abstract

Carotid-cavernous fistulas, characterized by abnormal arteriovenous communication within the cavernous sinus (CS), can be classified as direct or indirect. Direct fistulas are defined as a direct connection between the internal carotid artery (ICA) and CS, whereas indirect fistulas result from an abnormal connection between the CS and dural arterial branches. The first-line treatment for both types of fistulas is endovascular intervention, most commonly accomplished through the transarterial and transvenous approaches of the conventional pathway, including the ICA, inferior and superior petrosal sinuses, or basilar plexus. Nonetheless, a retrograde approach through the superior ophthalmic vein may be necessary for individuals in whom conventional endovascular treatment fails. Herein, the current principles of surgical indication and technique are presented, along with case studies.

Keyword

Carotid-cavernous fistula; Arteriovenous fistula; Superior ophthalmic vein; SOV approach

Figure

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  Fig. 1. (A) First, the SOV is assessed using Doppler ultrasound, marking the incision line along the sub brow area. (B) The incision is placed on the skin, orbicularis oculi muscle, and septum to avoid unwanted damage to the SOV and surrounding tissues. (C) Traction is made using 4-0 silk on the distal and proximal sides of the superior ophthalmic vein to make it easy to handle and control any unexpected bleeding. (D) The microcatheter is inserted through the SOV, and the patient should show normal finally coiling embolization of the CS, especially around the entrance site of SOV [21]. SOV, superior ophthalmic vein; CS, cavernous sinus

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  Fig. 2. (A) Angiography reveals increased flow to the SOV with the IPS obstruction (yellow triangle) in a patient with CS-dAVF on the right side. (B) After the SOV approach, the flow to the SOV is well occluded. SOV, superior ophthalmic vein; IPS, inferior petrosal sinus; CS-dAVF, cavernous sinus dural arteriovenous fistulas

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  Fig. 3. (A) Angiography confirms a severely dilated SOV with thromboembolic signs (yellow triangles) on the distal part of the SOV. (B) The patient shows total ophthalmoplegia, proptosis, ptosis, chemosis, and signs of optic neuropathy in her left eye. SOV, superior ophthalmic vein

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  Fig. 4. Three months after the first coil embolization of traumatic CCF, the fistula is recanalized and the SOV is severely enlarged. (A) The IPS obstruction, which is a conventional pathway to block the flow to the SOV is observed. (B) Through the SOV approach, the opening of the SOV and Sylvian vein are successfully occluded, and no symptoms remain after surgery. CCF, carotid-cavernous fistula; SOV, superior ophthalmic vein; IPS, inferior petrosal sinus

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  Fig. 5. (A) Thrombosis and comparted nature of CS make it challenging to approach the opening of the SOV and sphenopalatine sinus even after overcoming the IPS obstruction. (B) Using the SOV approach, the superior-anterior part of the CS is fully obstructed, and no flow is observed. CS, cavernous sinus; SOV, superior ophthalmic vein; IPS, inferior petrosal sinus

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