Embolization of Carotid Cavernous
Fistulae by transvenous approach through
the Facial Vein
Chao-Bao Luo, Michael MH Teng,
Feng-Chi Chang, Wan-You Guo
Department of Radiology, Taipei Veterans
General Hospital and National Yang-Ming
University
• Transvenous embolization of carotidcavernous fistulae (CCFs) through the inferior
petrous sinus (IPS) up to the cavernous sinus
(CS) is the common pathway while transarterial embolization fail to occlude the
fistulae.
• Trans-IPS is not always successful because
of occlusion/stenosis or difficult anatomy of
IPS.
Purpose of the study
• To increase the successful occlusion of
the CCFs with preservation of the ICA
flow (direct type), we present our
experiences of trans-facial vein (FV) to
embolize CCFs.
Patients and Methods (1)
• Over a 5-year period, a total of 76 CCFs
were referred to our institute for
endovascular embolization.
• Among these, 17 patients with CCFs
(direct type: 4, indirect: 13) were treated
by trans-FV embolization.
Patients and Methods (2)
• Trans-FV embolization was selected because
of thrombosis/occlusion (n=13), difficult
anatomy (n=1) or coil blockage (n=3) of the
IPS.
• Facial vein drains to external jugular vein in
13, while 4 drains to internal jugular vein.
• Trans-femoral vein approach in 16, while
direct puncture of jugular vein in 1.
• Trans-FV access via superficial facial vein in
16, while one through retromandibular vein.
• Detachable coils were selected to embolize in
all CCFs.
Results
• All CCFs were successfully accessed by
trans-FV catheterization; 16 fistulae were
totally occluded by detachable coils on
immediate angiography.
• One residual indirect CCFs spontaneous
thrombosis on 6-month follow up.
• One direct CCF had a recurrence and was
managed by direct puncture of cavernous
sinus with coil and NBCA embolization.
• There was no significant peri-procedure
complication or other recurrent or residual
fistula in an average of 9-month follow up.
Case illustrations
F/28 years old with
TCCF
Transretromandibular
vein, middle
temporal vein
F/34Y with
chemosis,
proptosis for
6 months
F/32y, bruit, chemosis
and proptosis of left eye
for 5 months
F/35y, bruit, chemosis of right eye
Male 52 y/o, presented with chemosis and proptosis
F/72,
chemosis
F/48, head
injury, chemosis,
decreased visual
acuity
Discussion
Trans-facial vein embolization of CCFs
• A very useful access to CCFs with
exclusively anterior drains to SOV and
facial vein.
Common venous routes to the CS
•
•
•
Trans-IPS
* via ipsilateral IPS
* via contralateral IPS >> inter-cavernous sinus
Trans-FV
* common FV >> superficial FV>> angular vein
>> nasofrontal vein >> SOV
* common FV>> retromandibular vein >>
middle temporal vein >> nasofrontal vein>>
SOV
Trans-SOV:
* by surgical exposure or direct puncture
Facial vein and Transfacial vein approach
Technique challenge of the trans-FV
embolization of the CCFs
1.To found the orifice of the common FV
• Choundhry et al (1997) found that 95% FV termination to the
internal jugular vein in the level of hyoid bone, only 5% drains to
external jugular vein.
• In this limited case study, 13 of 17 cases of common FVs drains to
external jugular veins. This may lead many error attempts and
unnecessary complication.
2. Long courses of facial vein
and/or narrow, tortuous courses
between angular vein--SOV and SOV-nasofrontal vein around the orbital
brim may make catheterization
difficult
Trans-facial Vs trans-SOV
access to embolize CCFs
• Trans-facial approach:
* less traumatic route, no require cut-down or
puncture of SOV, avoid scars.
* may fail due to long and tortuous course.
• Trans- SOV approach:
* bleeding from SOV, difficult to hemostasis.
* injury of supra-orbital nerve, trochlea, levator
muscle.
* Infection, granuloma.
Conclusions
• Knowledge of the varying venous patterns in
the neck and facial region is crucial for transFV approach of the CCF, in order to avoid
any intra-operative error procedure and
unnecessary complications.
• Trans-FV catheterization is usually successful;
it is a safe and effective approach and
provides a convenient alternative pathway for
transvenous embolization of CCFs when
failure to access the fistulae via the IPS.
Thank You for Your Attention
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