title: Submandibular puncture of the facial vein: an original route for endovascular therapy of cavernous sinus dural fistulas.
abstract: BACKGROUND
  Carotid cavernous sinus fistulas are a potentially severe pathology. Their basic standard treatment is an occlusion of the CCF performed by retrograde venous catheterization via the inferior petrous sinus. When the inferior petrous sinuses are occluded, other alternative venous routes are possible with various subsequent difficulties and risks. We report an original and safe method for endovascular treatment using submandibular puncture of the facial vein.
  
  
  METHODS
  We report 4 cases of patients with severe unilateral carotid cavernous sinus fistula associated with the occlusion of both inferior petrous sinuses. A submandibular surgical puncture of the ipsilateral inferior facial vein permitted the catheterization of the fistula. Complete occlusion of carotid cavernous sinus fistula was obtained by using a combination of microcoils and Onyx™.
  
  
  CONCLUSIONS
  When inferior petrous sinuses are occluded, endovascular treatment of carotid cavernous sinus fistulas is more difficult. After reviewing the other treatment options reported in the literature and their respective advantages and adverse effects, we describe an original technique based on the surgical puncture of the ipsilateral facial vein. The occlusion of the fistula is then obtained by using a combination of microcoils and Onyx™.
  
  
  CONCLUSIONS
  When the inferior petrous sinuses are occluded, an endovascular treatment for a carotid cavernous sinus fistula can be performed using an original and secure method. This method relies on a simple surgical puncture of the facial vein in the submandibular region, which then permits a retrograde catheterization of the carotid cavernous sinus fistula with no significant risk.
authors.affiliation: Service de neuroradiologie, hôpital de La Timone, CHU de Marseille, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France. Electronic address: Herve.brunel@ap-hm.fr.
authors.forename: H
authors.initials: H
authors.lastname: Brunel
authors.affiliation: Service de neuroradiologie, hôpital de La Timone, CHU de Marseille, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
authors.forename: N
authors.initials: N
authors.lastname: Girard
authors.affiliation: Service de neurochirurgie, hôpital de La Timone, CHU de Marseille, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
authors.forename: H
authors.initials: H
authors.lastname: Dufour
authors.affiliation: Service de radiologie, hôpital Sainte-Marguerite, CHU de Marseille, 270, boulevard Sainte-Marguerite, 13274 Marseille cedex 9, France.
authors.forename: P
authors.initials: P
authors.lastname: Peretti-Viton
authors.affiliation: Service de neuroradiologie, hôpital Gui-de-Chauliac, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
authors.forename: M
authors.initials: M
authors.lastname: Moynier
authors.affiliation: Service de neuroradiologie, hôpital Gui-de-Chauliac, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
authors.forename: A
authors.initials: A
authors.lastname: Bonafé
mesh_terms: D000368:Aged; D020216:Carotid-Cavernous Sinus Fistula / Q000601:surgery*; D002426:Cavernous Sinus / Q000601:surgery; D004338:Drug Combinations; D004621:Embolization, Therapeutic / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D005145:Face / Q000098:blood supply*; D005260:Female; D006801:Humans; D008297:Male; D008334:Mandible / Q000601:surgery; D008875:Middle Aged; D011145:Polyvinyls; D013635:Tantalum; D016896:Treatment Outcome; D014680:Veins / Q000601:surgery*
chemical_list: D004338:Drug Combinations; C558446:Onyx 18; D011145:Polyvinyls; D013635:Tantalum
keywords: Carotid cavernous fistula; Cavernous sinus; Embolisation transveineuse; Endovascular treatment; Fistule carotido-caverneuse; Onyx™; Sinus caverneux; Traitement endovasculaire; Transvenous embolization; Veine faciale