Article Figures & Data
Figures
- FIG 1.
Transvenous embolization of a right hypoglossal canal (anterior condylar) dAVF using a reverse pressure cooker technique in a 47-year-old man for management of refractory pulsatile tinnitus. A, CT angiogram (axial) demonstrates increased vascularity surrounding the right hypoglossal canal (white arrow) with arterialization of the right anterior condylar vein, suggestive of a dAVF. B, Right lateral ECA cerebral angiography confirms the diagnosis, with primary arterial supply via neuromeningeal trunk branches (black arrow) of the right ascending pharyngeal artery (inset, selective right ascending pharyngeal artery injection). C, Lateral fluoroscopy roadmap of transvenous treatment shows a 6F Destination sheath (Terumo) positioned in the right internal jugular vein (white arrowhead), through which a SONIC 1.5F microcatheter (Balt) with a 4.5-cm detachable tip was positioned at the fistulous point (white arrow). D, A 1.5F Marathon microcatheter (Covidien) was placed in the anterior condylar confluence to deploy 7 detachable coils, with the coil mass demonstrated in the working projection. E, The Marathon microcatheter was removed, and the SONIC microcatheter was primed with dimethyl-sulfoxide before forming an Onyx (Covidien) cast at the fistulous point. F, Right ECA lateral projection angiography demonstrates complete occlusion of the fistula.
- FIG 2.
Bilateral indirect CCFs treated with transvenous embolization via right inferior petrosal sinus and left facial vein approaches. A, A 64-year-old woman presented with right-sided ptosis and loss of vision, investigated with a TOF-MRA that demonstrates arterialization of the bilateral superior ophthalmic veins (white arrowheads). B, Frontal-projection left ECA angiography demonstrates an indirect CCF with supply from dural branches of the bilateral ECAs and ICAs, with the right cavernous sinus opacifying earlier than the left (white arrows) and reflux into the bilateral superior ophthalmic veins (white arrowheads). C, Transvenous treatment fluoroscopy in a frontal projection shows positioning of a 6F Envoy catheter (Cordis) (black arrow) into the proximal right inferior petrosal sinus, with an Excelsior SL-10 microcatheter (Stryker) advanced into the right cavernous sinus. Subsequent coil embolization of the proximal right superior ophthalmic vein, right cavernous sinus, and medial left cavernous sinus through the intercavernous sinus was followed by injection of 33% glue (Glubran n-BCA; GEM Italy) in Lipiodol (Guerbet) into the right-sided coil mass. There was resolution of the patient’s symptoms; however, a few weeks later she developed left-sided chemosis. Frontal (D) and lateral (E) projection right ECA angiography demonstrates progression in the left cavernous sinus arteriovenous shunting, with prominence of the left superior ophthalmic (white arrowhead) and facial (asterisk) veins. No outflow is identified into the left inferior petrosal sinus, which is likely thrombosed. F, Lateral-projection fluoroscopy shows how a 6F Navien intermediate catheter (Covidien) was advanced via the left internal jugular vein into the left facial vein (black arrow) mounted on a Prowler Plus microcatheter (Codman Neurovascular). The Prowler Plus was then navigated through the left facial, angular, and superior ophthalmic veins into the left cavernous sinus (black arrowhead) and used to embolize with coils.
- FIG 3.
Transvenous embolization of a left petrous ridge dAVF using a modified reverse pressure cooker technique. A 49-year-old man presented with a 3-month history of headache and left-sided pulsatile tinnitus. A, TOF-MRA demonstrates prominence of vessels along the left petrous ridge with arterialization of the left superior petrosal vein of Dandy (white arrowhead). B, Lateral-projection left ECA angiography confirms the presence of a left petrous dAVF centered on the superior petrosal vein of Dandy (black arrow), with direct cortical venous drainage (open arrowhead) supplied by left middle meningeal artery petrous branches (white arrow) and a left accessory meningeal artery (white arrowhead). C, Transvenous treatment was performed to avoid embolization of the neighboring facial arcade. A left ECA roadmap in a lateral projection demonstrates a 6F Destination sheath placed in the left internal jugular vein (black arrowhead), with a Fargo-Mini intermediate catheter (Balt Extrusion) (black arrow) used to support advancement of a Marathon microcatheter to the fistulous site (white arrowhead). Lateral-projection fluoroscopy was performed after 3 coils were deployed (D) and then after Onyx-18 was used to embolize the distal arterial feeders, fistula site, and proximal draining vein, creating a coil-Onyx mass (E). This was a modification of the reverse pressure cooker technique using a single flow-directed microcatheter (Marathon) without a detachable tip to perform both the coiling and the EVOH injection. This modification was required due to the extensive tortuosity of the transvenous course that impeded attempts to place 2 microcatheters and required the use of a low-profile intermediate catheter (Fargo-Mini) (black arrow). The Marathon microcatheter could not be removed and was left in situ and cut at the level of the right femoral subcutaneous soft tissue. This procedure is typically well-tolerated in the venous system, and the patient was placed on a 6-month course of anticoagulation. F, Follow-up lateral-projection left ECA angiography at 6 months demonstrates complete occlusion of the fistula.
