title: Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein.
abstract: OBJECTIVE
  To describe indications and surgical techniques for embolization of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a cannulated superior ophthalmic vein based on our clinical experience.
  
  
  METHODS
  Retrospective clinical review.
  
  
  METHODS
  University tertiary referral hospital and eye institute.
  
  
  METHODS
  Over a 3-year period, 10 consecutive patients with CDF and progressive orbital congestion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatment of fistulas on the basis of progressive glaucoma refractory to medical management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combination of these findings.
  
  
  METHODS
  Nine of the 10 patients underwent anterior orbitotomy via a lid-crease or sub-brow incision with cannulation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful transarterial embolization. One patient underwent a primary transvenous embolization.
  
  
  METHODS
  Successful closure of the fistula on angiography, return of baseline visual acuity, normalization of postoperative intraocular pressure, and cosmetically acceptable cutaneous scar.
  
  
  RESULTS
  All 10 patients had prompt resolution of symptoms and halt of progressive visual loss following occlusion of the fistulas. Two patients had no flow in the anterior superior ophthalmic vein on angiography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization was successfully performed. In 2 additional patients with nondilated superior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small vein.
  
  
  CONCLUSIONS
  When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for CDF and perhaps should be employed as primary therapy in cases with progressive orbital congestive symptoms. If the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.
authors.affiliation: Department of Orbital and Ophthalmic Plastic and Reconstructive Surgery, Jules Stein Eye Institute, Los Angeles, USA.
authors.forename: R A
authors.initials: RA
authors.lastname: Goldberg
authors.forename: S H
authors.initials: SH
authors.lastname: Goldey
authors.forename: G
authors.initials: G
authors.lastname: Duckwiler
authors.forename: F
authors.initials: F
authors.lastname: Vinuela
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001164:Arteriovenous Fistula / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D002340:Carotid Artery Diseases / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D002342:Carotid Artery, External / Q000002:abnormalities / Q000000981:diagnostic imaging; D002343:Carotid Artery, Internal / Q000002:abnormalities / Q000000981:diagnostic imaging; D002426:Cavernous Sinus / Q000002:abnormalities* / Q000000981:diagnostic imaging; D002533:Cerebral Angiography; D004388:Dura Mater / Q000098:blood supply*; D004621:Embolization, Therapeutic / Q000379:methods*; D005123:Eye / Q000098:blood supply*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014680:Veins; D014792:Visual Acuity