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Stereotactic-guided direct orbital puncture for treatment of orbital arteriovenous fistula
  1. Ariadna Robledo1,
  2. Thomas S Frank1,
  3. Patrick J Karas1,
  4. Hashem Shaltoni2,
  5. Sean O'Leary1,
  6. Robert Darling3,
  7. Peter Kan1
  1. 1Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  2. 2Neurology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  3. 3Otolaryngology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  1. Correspondence to Dr Ariadna Robledo, Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA; arrobled{at}


The patient presented with left-sided chemosis, exophthalmos, and progressive visual loss. Cerebral angiography ed a left orbital arteriovenous malformation and an associated hematoma, with the point of fistulation between the left ophthalmic artery and the anterior section of the inferior ophthalmic vein, with retrograde flow through the superior ophthalmic vein. Transvenous embolization through the anterior facial and angular veins was unsuccessful, with residual shunting. Stereotactic-guided direct venous puncture and Onyx embolization was subsequently performed in the hybrid operating room (OR) to cure the fistula. A subciliary incision allowed for retraction of the orbital contents, creating an optimal trajectory. An endonasal endoscopic approach was performed after the embolization to decompress the orbit. This procedure is shown in video 1.1–11

Video 1

  • Fistula
  • Navigation
  • Orbit
  • Technique
  • Liquid Embolic Material

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  • 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 PK discloses leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid PK Journal of Neurointerventional Surgery (JNIS) member of the Editorial Board.

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