Transvenous Embolization of Cavernous and Paracavernous Dural Arteriovenous Fistula through the Facial Vein: Report of 12 Cases
A 20-year-old man was admitted with left-sided exophthalmos and chemosis. Enhanced orbit MRI revealed a lobulated mass-like lesion at the left sphenoid bone with extension to the orbit and middle cranial fossa, and it showed strong enhancement. DSA showed an arterio-venous fistula involving the left frontal region, with shunt flow from the middle meningeal artery, draining into the dilated venous, and then into LWSS and SOV through CS (). We decided to occlude the fistula portion involving middle meningeal artery and performed embolization for the lesion via arterial approach using detachable and pushable fibered coils. The post-procedural angiography showed occlusion of internal maxillary artery but other fistula from ophthalmic artery was seen. The exophthalmos and chemosis improved in some degree after the procedure and the patient discharged, pledging to treat the remnant lesion again. After the initial treatment, follow-up angiography showed remained arterio-venous shunt at left LWSS, with arterial feeders including left middle meningeal artery and branch of inferolateral trunk from the left ICA, and venous drainage mainly into the SOV via left CS with small amount of venous drainage also into the left IPS. Under general anesthesia, initially a pre-shaped 45-degree microcatheter (Excelsior SL-10, Boston Scientific, Natick, MA, USA) was placed in the left middle meningeal artery. Liquid embolic agent (Onyx, Micro Therapeutics, Irvine, CA, USA) was prepared and injected through the microcatheter. The arteriovenous shunt from the left middle meningeal artery was completely occluded but the left LWSS region remained. We decided to approach for the fistula through venous route. A microcatheter was placed in the left IPS, and the left CS was selected. However, it could not be further advanced due to acute angle at the connection site between the left CS and LWSS. Other venous route was decided and we attempted to select FV. The microcatheter was placed in the left FV and SOV, and then it was placed at the venous side near the arteriovenous shunt site at left LWSS. The remnant shunt was completely occluded by coils. The exophthalmos was resolved immediately after the procedure.