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Case series
Direct puncture of the superior ophthalmic vein for carotid cavernous fistulas: a 21-year experience
  1. Joshua S Catapano,
  2. Visish M Srinivasan,
  3. Nicole M De La Peña,
  4. Rohin Singh,
  5. Tyler S Cole,
  6. D Andrew Wilkinson,
  7. Jacob F Baranoski,
  8. Caleb Rutledge,
  9. Mark A Pacult,
  10. Ethan A Winkler,
  11. Ashutosh P Jadhav,
  12. Andrew F Ducruet,
  13. Felipe C Albuquerque
  1. Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
  1. Correspondence to Dr Felipe C Albuquerque, c/o Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA; neuropub{at}


Background Direct puncture of the superior ophthalmic vein (SOV) is an alternative approach to traversing the inferior petrosal sinus for embolization of carotid cavernous fistulas (CCFs).

Objective To analyze direct SOV puncture for the treatment of CCFs and review the literature.

Methods All patients at a single center, treated for a CCF with direct SOV cannulation between January 1, 2000, and December 31, 2020, were retrospectively analyzed. An additional review of the literature for all case series for direct puncture of the SOV for treatment of CCF was performed.

Results During the 21-year study period, direct cannulation of the SOV for treatment of a CCF was attempted for 19 patients, with the procedure aborted for one patient because of an inability to navigate the wire into the distal aspect of the cavernous sinus. In 18 patients with direct SOV CCF treatment, 1 experienced a minor complication with an asymptomatic postoperative hemorrhage. Angiographic cure and improvement of symptoms were achieved in 17 patients with a mean (SD) follow-up of 6 (5.2) months. In the review of the literature, an additional 45 patients were reported to have direct cannulation of the SOV for CCF treatment, with angiographic cure in 43 (96%) and decreased objective visual acuity in 1 (2%).

Conclusion Direct SOV cannulation to treat CCFs is safe and effective. Although it is typically used after other endovascular approaches have failed, SOV access for CCF treatment may be warranted as a first-line treatment for select patients.

  • Hemorrhage
  • Stroke
  • Fistula

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  • Contributors All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and drafted the work or revised it critically for important intellectual content; and provided final approval of the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work is appropriately investigated and resolved. JSC: writing; VMS: edits; NMDLP: data collection; RS: data collection and literature review; TSC: edits; DAW: edits; JFB: edits; CR: edits; MAP: data collection; EAW: edits; APJ, final edits; AFD: final edits; FCA: final edits and final approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests FCA and AFD serve on the editorial board of the Journal of NeuroInterventional Surgery.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.