title: Transorbital endovascular embolization of dural carotid-cavernous fistula: access to cavernous sinus through direct puncture: case examples and technical report.
abstract: OBJECTIVE
  We present 2 cases of carotid-cavernous fistulas that failed multiple attempts at transarterial and transvenous embolization. Direct transorbital puncture for embolization was successful in curing the fistulas. The relevant anatomy and technique are reviewed.
  
  
  METHODS
  The first case is a 39-year-old man who presented with a 2-month history of worsening right-sided chemosis, proptosis, double vision, and progressive right eye vision loss. The second case is a 79-year-old woman with a 5-month history of right-sided chemosis and a 1-month history of complete left ophthalmoplegia. Cerebral angiography revealed an indirect carotid-cavernous fistula (CCF) in both patients, supplied by meningeal branches of the internal and/or external carotid arteries.
  
  
  METHODS
  After multiple unsuccessful attempts at transarterial and transvenous embolization, the CCFs were accessed via direct percutaneous transorbital puncture of the inferior and superior ophthalmic veins, respectively. The fistulas were then successfully occluded with a combination of Onyx and detachable coils.
  
  
  CONCLUSIONS
  In rare cases in which more conventional transvenous and transarterial routes to a CCF have been exhausted, direct percutaneous transorbital puncture represents a viable means of achieving catheterization of the fistulous connection. In most cases, where a prominent arterialized superior ophthalmic vein is present, direct puncture represents a reasonable alternative to ophthalmologic cut-down procedures. Transorbital puncture of the inferior ophthalmic vein provides a direct route to the cavernous sinus in cases where the superior ophthalmic vein is atretic and inaccessible by direct surgical cut-down procedures.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Shervin R
authors.initials: SR
authors.lastname: Dashti
authors.forename: David
authors.initials: D
authors.lastname: Fiorella
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
mesh_terms: D000328:Adult; D000368:Aged; D000792:Angiography; D020216:Carotid-Cavernous Sinus Fistula / Q000601:surgery*; D002426:Cavernous Sinus / Q000601:surgery*; D004621:Embolization, Therapeutic / Q000379:methods*; D057510:Endovascular Procedures / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D011677:Punctures / Q000379:methods