Transorbital, Transvenous Endovascular Embolization of a Petrous AVM/DAVF through Microsurgical Cannulation of the Superior Opthalmic Vein - Case Report and Technical Note

Objective: The superior ophthalmic vein (SOV) has been described in the literature as an alternative venous access typically for the treatment of carotid-cavernous fistulae. Its direct surgical exposure and cannulation might be challenging. Nevertheless, this approach can be advantageous to coil dural arteriovenous fistulas or malformations in deep intracranial locations or when the internal jugular vein or petrosal sinus are impeded or the normal venous routes are inaccessible. We report the technical aspects of a case undergoing transvenous endovascular treatment of an AVM (Spetzler Martin IIa) associated with a DAVF of the Sinus petrosus (Cognard IV) which was embolized by an SOV approach.

Clinical Presentation: A 61-year-old male patient first presented in 2015 with a symptomatic SAH with hydrocephalus. Within three months ∼80% of the feeding branches were embolized in two endovascular sessions. There was no further option for an transarterial access. In a third endovascular session, a transvenous approach through the inferior and superior pertrosal sinus, transverse sinus and cavernous sinus into the perimesencephalic veins was emerged technically inaccessible. After discussion in our cerebrovascular board, a transorbital, transvenous approach through the SOV in the hybrid OR (hOR) was proposed.

Intervention: The interdisciplinary procedure took place in our hOR. A shaped eyebrow incision under the microscope was performed. After preparation of the supraorbital fat, the supraorbital vein and SOV were identified. The cannulation of the vein using a 14-G (diameter: 2.11 mm) catheter enabled the retrograde transvenous embolization of remaining shunts and a pontomesencephal venous pouch with 21 coils without complications. The intraoperative final angiography demonstrated a complete occlusion of the mesencephalic and pontine shunts and downstream venous vessels without an impairment of infratentorial venous drainage. The cannula was removed and the wound closed after proximal coagulation of the SOV. The patient recovered uneventfully and could be discharged on day 5th after surgery. At 3 months F/U no neurological deficits and excellent cosmetic results could be documented.

Conclusion: Interdisciplinary transvenous endovascular treatment of complex petrous AVM/DAVF using the transorbital cannulation of the SOV is a feasible, time-saving and safe procedure if performed in the environment of the hOR.