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Trans-arterial embolisation therapy of dural carotid–cavernous fistulae using low concentration n-butyl-cyanoacrylate

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An Erratum to this article was published on 22 July 2009

Abstract

Background

Trans-venous embolisation has been accepted as the preferred treatment for dural carotid–cavernous fistulae (DCCF). However, such an approach is not always feasible. In this circumstance, trans-arterial embolisation with low concentration n-butyl-cyanoacrylate glue (NBCA) may be a feasible alternative. We report our results and experience of this method for DCCF.

Materials and methods

Five patients with DCCF were treated by trans-arterial embolisation using low concentration NBCA by wedging the microcatheter into the main feeding artery. All five lesions were associated with venous drainage into the superior ophthalmic vein. The inferior petrosal sinus was patent in one patient and thrombosed in four. Additional venous drainage into the Sylvian vein and the superior petrosal sinus was observed in two patients.

Findings

The definitive NBCA injection was performed via the branches of the middle meningeal artery in three patients and accessory meningeal artery as well as ascending pharyngeal artery in two patients. Four patients showed complete obliteration of the DCCF on the post-embolisation angiogram, and follow-up studies showed clinical cure or improvement and successful obliteration of the DCCF. One patient had a residual DCCF after the procedure, but showed complete obliteration and clinical cure at 5-month follow-up. Glue penetrated into the Sylvian vein in one patient during the procedure without sequelae. Two patients had transient worsening of ocular symptoms after the procedure.

Conclusions

Trans-arterial embolisation with low concentration NBCA using a wedged microcatheter technique is still a safe and effective treatment for DCCF when the transvenous approach is not feasible. However, care must be taken to prevent inadvertent arterial and venous embolisation.

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Authors and Affiliations

  1. Department of Radiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University, 600, Yi Shan Road, Shanghai, 200233, China

    Ming-Hua Li, Hua-Qiao Tan, Chun Fang, Yue-Qi Zhu, Wu Wang, Jue Wang & Ying-Sheng Cheng

Authors
  1. Ming-Hua Li
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  2. Hua-Qiao Tan
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  3. Chun Fang
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  4. Yue-Qi Zhu
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  5. Wu Wang
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  6. Jue Wang
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  7. Ying-Sheng Cheng
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Correspondence to Hua-Qiao Tan or Chun Fang.

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Comment

An extensive literature has been written on dural arterio-venous fistulas (DAVFs) of the cavernous sinus, and various managements have been proposed to treat these lesions. Endovascular approach of the cavernous sinus through venous route (via the inferior petrosal sinus, pterygoid plexus, ophthalmic vein via direct puncture or facial navigation) with coiling of the venous compartment draining the shunt is considered to be the best and safest treatment for these complex lesions, and transarterial embolization has been rarely proposed. The authors report in this paper their experience in five patients with dural shunts of the cavernous sinus that have been treated by transarterial embolization with glue. This paper is interesting as it opens a debate concerning the interest and risks of this technique, and the use of liquid emboli in these lesions. The problems raised by transarterial embolization in DAVFs of the cavernous sinus are indeed triple: one must navigate through tiny tortuous arterial feeders arising from internal or external carotid arteries that are nearly always neuro-dural arteries also vascularizing cranial nerves (CN), one must occlude selectively the shunting zone without being proximal in order to respect the CN vascularization, and one has to avoid the dangerous arterial anastomoses at the skull base. The main challenge in transarterial embolization of DAVFs of the cavernous sinus is thus much more anatomical than technical. All these procedures have to be performed under General Anaesthesia in order to allow precise depiction of all feeders taking in charge the shunt. The cavernous sinus region is indeed an important anatomic crossroads between external and internal carotid vascularizations, and transarterial embolization has thus to be performed in perfect anatomic conditions with precise recognitions of the dangerous points of the artery that is catheterized and occluded. Major complications can occur (CN palsies, erratic emboli in the ophthalmic artery or in the intracranial internal carotid artery) if the procedure is poorly achieved. Proper permanent occlusion of the shunt is only obtained with liquid emboli. Particles create transitory occlusions and rarely cure the lesion: their use should thus be nowadays limited to flow redistributions in order to allow secondarily better endovascular occlusions through a main feeder.

Transarterial deposition of coils is inadequate because of the proximal occlusion that will be created. Only fluid agents are useful emboli here: the risk they carry are not related to their physical characteristics but rely on anatomic traps that are scattered all along the traject of the neuro-dural arteries before reaching the shunt itself. Glue is an ?old? embolic agent that has proven since more than 30 years its efficiency in the endovascular management of arterio-venous malformations. Injected diluted and in wedge position in the arterial feeder, it can penetrate deeply into the DAVF; furthermore, because of its three effects(inflammatory, thrombotic, thermic), glue may allow secondary thrombosis of the shunt. It is a cheap product in comparison to Onyx that is considered by certain teams nowadays as a reference embolus . The long term follow up of Onyx is however not known at this stage. The debate that could be created between the supporters of Onyx and those of glue is thus a wrong debate that should not mask the need of precise anatomic knowledge in cavernous DAVFs. The therapeutic decisions have to be taken on a case-by-case basis. Venous approach should be privileged whenever possible. Glue can be injected also directly into the venous compartment draining the shunt : the cavernous sinus being in fact a plexus, occlusion of one channel may not compromise the venous drainage of other compartment. Compression of the superior ophthalmic vein at the internal canthus remains an appropriate technique in cases of DAVFs draining exclusively into that system. Transarterial embolization of these lesions should only be offered in specific indications after careful evaluation. It should be balanced against other therapeutic managements known to also offer good results in these lesions, as radiosurgery.

Georges Rodesch

Hôpital Foch, Suresnes, France

An erratum to this article can be found at http://dx.doi.org/10.1007/s00701-009-0458-3

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Li, MH., Tan, HQ., Fang, C. et al. Trans-arterial embolisation therapy of dural carotid–cavernous fistulae using low concentration n-butyl-cyanoacrylate. Acta Neurochir (Wien) 150, 1149–1156 (2008). https://doi.org/10.1007/s00701-008-0133-0

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