Retrograde facial vein approach in the transvenous embolization of CSDAVF

Both ECA grams

Right ICA gram

Right ICA gram

Dural branches

Right ICA roadmap showing venous drainage

Right middle temporal vein

Left EJV

Left middle temporal vein

Left supraorbital vein

Transverse facial vein

Retrograde guidewire placement

Final control angiography confirmed complete occlusion of the shunt

• Conservative management
  • If patient's condition is tolerable
• Surgery
  • Not an indication
• Gamma knife
  • In limited situations due to the risk of cranial nerve palsy
• Endovascular
  • Transarterial
    • Risk of CN injury
  • Transvenous
    • The most effective approach

Transvenous access into the CS

• Ipsilateral or contralateral IPS via the IJV (commonly used)
• SPS via the transverse sinus
• SOV via the angular vein
• SOV via the middle temporal vein or superficial temporal vein
• Pterygoid plexus via the maxillary vein

_{Clinical and Experimental Ophthalmology, John ZhangandMark D StringerMS FRCS 2010; 38: 502–510 doi: 10.1111/j.1442-9071.2010.02325.x}

The common facial vein (CVF), anterior facial vein (AFV), angular vein (AV), retromandibular vein (RMV), middle temporal vein (MTV), superficial temporal vein (STV), and cavernous sinus (X) are highlighted.

The anterior facial vein (solid arrow), angular vein (black arrow) and superior ophtalmic veins (white arrow) are shown.

Access to the retrograde SOV can be achieved by?

• The angular vein via the facial vein
• The supraorbital vein via the middle temporal or superficial temporal vein

Consideration

• Redundant venous access route requiring a longer microcatheter
• Use a short guiding catheter to minimize the dead length of the coaxial system
• Anatomic complexity at the junction with the SOV at the supraorbital margin

In the endovascular treatment of dural CCF, the transfemoral approach of the cavernous sinus via the facial vein/STV provides a valuable and safe alternative, despite the complexity of the anatomical variation, this approach is indicated if :

1. Venous drainage to the SOV exists and IPS is thrombosed
2. No communication between the IPS and the fistula site,
3. If the IPS approach has failed.