Background Cavernous carotid arteriovenous fistulas (CCFs) are a relatively rare but fairly well documented intracranial vascular pathology. The most frequently utilized approach to treatment is endovascular embolization, via either transvenous or transarterial approaches, in order to close the venous outflow or limit the arterial inflow. The adopted standard algorithm to these options is to first attempt mapping a venous tract for catheterization. Frequently, the morphology of the venous drainage is in-sufficient for catheterization. Trans-arterial embolization is typically reserved for these instances given the well documented risks, including cranial nerve injury which approaches a 10% overall risk of complication. A third and less commonly used alternative for treating these difficult CCFs involves direct percutaneous access to the fistula. There are few published case reports documenting this direct access method, including our previous work describing a case in which we treated a clival dural arteriovenous fistula via direct access through the foramen ovale. Since our prior reporting, we have compiled a case series of percutaneous direct access to difficult CCFs from both foramen ovale and transorbital approaches.
Purpose The goal of this case series is to describe, with graphic illustrations, the appropriate techniques for treating difficult CCFs with direct percutaneous access, specifically using a transforaminal approach through the foramen ovale and transorbital approach.
Methods We intend to describe the pearls and pitfalls of percutaneous access, specifically with regards to the risks and benefits of this technique, as well as de-scribing the ideal situations, which may make one approach more optimal than an-other. We also intend to provide anatomic illustrations demonstrating fluoroscopic, 3D, and graphic representations of the pertinent adjacent anatomic structures and proper landmarks for employing this technique.
Results Our series of patients treated with percutaneous direct access demonstrated long-term fistula occlusion and resolution of clinical symptoms. There was no elevated rate of complication or bleeding in our cohort.
Conclusion Successful occlusion of dural arteriovenous fistulas using percutaneous access provides a salient alternative for difficult CCFs if performed correctly and with respect to anatomical hazards.
Disclosures J. Van Rompaey: None. R. Darflinger: None. K. Chao: None. L. Feng: None.