Transorbital embolization of bilateral caroticocavernous fistula via an unilateral inferior ophthalmic vein approach

Discover the case of an 81-year-old male patient with a complex presentation of bilateral carotid cavernous fistula (CCF), exhibiting acute symptoms including left ptosis, diplopia, bilateral chemosis and cranial nerve palsies. Conventional embolization routes were not feasible due to occlusions and stenosis in various venous pathways. Thus, a hybrid surgical and endovascular approach was employed, utilizing a direct access technique via the right inferior ophthalmic vein (IOV).

Case presentation

Patient presentation

M/81
Acute onset (10 day history):
- left ptosis
- diplopia
Physical examination:
- bilateral chemosis
- right CN VI palsy
- left CN III (with pupil involvement) and CN VI palsy
Clinical diagnosis:
- Caroticocavernous fistula (CCF)

Right & Left ECA - AP angiograms

Right ICA - Lateral angiogram

Embolization targets

Bilateral cavernous sinuses
Intercavernous sinus
Bilateral SOV and IOV
Cortical veins with reflux

Approach

Conventional routes:
- Occluded bilateral inferior petrosal sinuses
- Significant stenosis in lower part of right facial vein
- Occluded bilateral superior ophthalmic veins (SOV)
- Significant stenosis at entry site of vein of Trolard into superior sagittal sinus
Available routes:
- Direct access of right inferior ophthalmic vein (IOV)
- Direct access of right vein of Trolard

Intervention

Right IOV surgical exposure for access

Right IOV access with 22G IV cannula

Right IOV - venogram

Right IOV - access

Only a 2cm segment of right IOV after which there is an acute 90 degree turn to a bridging vein to right SOV
Shortest length of available vascular sheaths is 4cm
Direct access with a 1.7Fr microcatheter over a 0.014” microguidewire

Right cavernous sinus

Direct catheterization

Left cavernous sinus

Catheterization and venogram

Coil embolization

Coil embolization of left SOV, left IOV, left cavernous sinus, intercavernous sinus
Minimal purchase margin of microcatheter available during coiling of right cavernous sinus
Switched to liquid embolization

Post-embolization angiograms

Right ECA – AP and Lateral

Post-embolization angiograms

Right ICA – Lateral

Clinical course

Clinical follow-up at 2 weeks, 3 months, 6 months and 18 months post-embolization:
- Resolved bilateral chemosis
- Resolved left ptosis
- Resolved diplopia
- Resolved bilateral cranial nerve palsies
- No visual impairment

Conclusions

Bilateral CCF with cortical venous reflux, with occlusion or significant stenosis along conventional venous embolization routes
Hybrid surgical and endovascular approach with access via right inferior ophthalmic vein
Short segment of the accessed right IOV requiring direct microcatheter access without vascular sheath
Combination of coil and liquid embolization due to limited microcatheter purchase margin during ipsilateral side embolization