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Table of Contents    
Year : 2011  |  Volume : 59  |  Issue : 1  |  Page : 92-96

Transvenous treatment of complex cavernous dural arteriovenous fistulae with Onyx and coils

Radiology Department, Bethune International Peace Hospital, Shijiazhuang, Hebei Province, China

Date of Submission24-Feb-2010
Date of Decision22-Jul-2010
Date of Acceptance06-Aug-2010
Date of Web Publication18-Feb-2011

Correspondence Address:
Jin-guo Cui
Radiology Department, Bethune International Peace Hospital, Shijiazhuang, Hebei Province - 050082
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.76877

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 » Abstract 

Transvenous embolization has become the treatment of choice for such lesions We evaluated Onxy for patients with cavernous dural arteriovenous fistulae (CDAVFs) who underwent transvenous embolization via different transvenous approaches. Case records of six patients with symptomatic CDAVFs, treated between October 2006 and November 2007 were reviewed. A total of seven transvenous procedures were performed in the six patients with CDAVFs. All the patients with CDAVFs of the cavernous sinus were symptom free following embolization. The approach via the internal jugular vein and the inferior petrosal sinus was possible in four of the six patients, with complete occlusion of the fistula. In the remaining two patients, the approach was via the facial vein. Transient bradyarrythmia without morbidity was the only complication in two patients.

Keywords: Arteriovenous fistula, cavernous sinus, dural arteriovenous malformation, transvenous embolization

How to cite this article:
Li L, Cui Jg, Liang Zh, Xu Sb, Li J, Tian Hq, Fan Yh. Transvenous treatment of complex cavernous dural arteriovenous fistulae with Onyx and coils. Neurol India 2011;59:92-6

How to cite this URL:
Li L, Cui Jg, Liang Zh, Xu Sb, Li J, Tian Hq, Fan Yh. Transvenous treatment of complex cavernous dural arteriovenous fistulae with Onyx and coils. Neurol India [serial online] 2011 [cited 2023 Dec 1];59:92-6. Available from:

 » Introduction Top

The decision to treat carotid cavernous fistulae (CCFs) is based on several factors: pattern of venous drainage, natural history of the lesion, severity of presenting symptoms, age and general condition of the patient, angiographic characteristics (number and location of feeders, location of dural arteriovenous fistulae DAVFs), and the procedure related morbidity and mortality rates. [1] Treatment goals include obliteration of the fistulae and relief from the symptoms. Treatment modalities of cavernous dural arteriovenous fistulae (CDAVFs) include: endovascular procedures with transvenous, transarterial or transarterial-transfistulous embolization, [2],[3],[4],[5],[6] surgery to access the fistula for embolization either on the venous or the arterial side or to excise the fistula, [7],[8],[9] gamma knife surgery [10] or combinations of any of the three. [4],[11],[12] Some lesions may require only conservative treatment. [13] Because of frequent recanalization and low cure rates, [6] transarterial embolization is limited to Barrow type C fistulae and Barrow Type D fistulae. Transvenous embolization has become the treatment of choice for such lesions. [5],[14],[15] In this article, we evaluated the efficacy and safety of different transvenous embolization techniques for the treatment of CDAVFs, with an emphasis on the use of Onyx via different transvenous routes.

 » Patients and Methods Top

The case records of six patients with CDAVFs treated between October 2006 and November 2007, via different endovascular transvenous routes, were retrospectively analyzed. The data are presented in [Table 1].
Table 1: Clinical features of patients who underwent transvenous embolization of arteriovenous fistulae of the cavernous sinus

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Bilateral selective internal carotid artery (ICA) and external carotid artery (ECA ) angiography and vertebral artery angiography were performed in all the patients to assess the feeding arteries, fistula sites and venous drainage. The arteriovenous malformations were approached via the venous route. We first placed 6-French sheaths in the femoral artery and vein. A 5-French catheter in the carotid artery allowed observation of the shunt, acquisition of roadmaps and angiographic monitoring of the procedure. A second 5-French guiding catheter was positioned in the jugular vein. A microcatheter (Echelon10/Marathon, MTI-EV3, Irvine, CA, USA) was navigated coaxially via different venous approaches. The microguiderwire (Silverspeed10/Mirage, MTI-EV3, Irvine) was then carefully introduced and advanced into the cavernous portion, followed by the microcatheter. All embolizations were performed with Onyx or combined with detachable coils using real-time digital subtraction fluoroscopic mapping.

Six patients (one female and five male patients; age range, 36-69 years, mean age, 52.3 years) presented with spontaneous DAVFs of the CS of Barrow Types C to D (Type C, n = 1; Type D, n = 5). Neurologic findings included third cranial nerve palsy in 3, exophthalmos in 2, chemosis in 2, pulsatile tinnitus in 2 and sixth cranial palsy in 1. All the six AVFs of CS were Type IIa. [16] The clinical follow-up periods after endovascular treatment ranged from 1 to 13 months (mean, 7.3 months).

 » Results Top

Transvenous embolization of the CS

A total of seven transvenous approaches were performed in the six patients with AVFs of the CS. The data are summarized in [Table 1]. Of the five patients with Barrow Type D fistulae, one was treated initially via the transarterial approach and subsequently via the transvenous route. Other patients with CDAVFs were initially teated via the transvenous route. If the drainage was predominant posteriorly, the approach was via the internal jugular vein (IJV)-inferior petrosal sinus (InfPS)-CS (n = 4). If the InfPS could be passed (n = 4), then the success rate was high, with complete occlusion in four patients. The transvenous approach via the facial vein (FV) exhibited technical success; complete occlusion of the fistula was possible in the two patients.

All the six patients with DAVFs of the CS had relief of clinical symptoms. Two patients had , transient bradycardia related to dimethyl sulfoxide (DMSO) injection. However, there was no permanent morbidity related to this event.

Illustrative case

Patient 4

A 54-year-old man presented with left sixth cranial nerve palsy and left pulsatile tinnitus. Cerebral angiogram showed Barrow Type D/Cognard Type IIa DAVF, with drainage into both CSs and, predominantly, the inferior petrosal sinus on the left side [Figure 1]a and 1b. There were multiple feeders arising from both the ICAs and the ECAs. Because of opacification of the left InfPS, this approach was chosen. Packing of the left CS with coils and Onyx occluded the fistula. Control angiography performed on both sides demonstrated complete occlusion of the fistula [Figure 1]c to e. The VIth cranial nerve palsy improved the following day.
Figure 1: (a)Left ECA arteriogram (lateral projection) showing filling of the CS and inferior petrosal sinus (InfPS) by multiple dural branches (the middle meningeal artery branches and the artery of the foramen rotundum)
Figure 1b: Arteriogram of the right common carotid artery (arterial phase, arteroposterior view), demonstrating multiple fistula feeders within the wall of the intercavernous sinus (arrow), arising from the ICA, with drainage into the left CS via the intercavernous sinus and into the left InfPS
Figure 1c: Unsubtracted frontal view after a transvenous approach showed the Onyx packing of the left CS and the left InfPS– CS route (arrowheads)
Figure 1d: Arteriogram of the right common carotid artery (anteroposterior view) after complete embolization of the fistula
Figure 1e: Anterogram of the left CCA (anteroposterior view), demonstrating complete occlusion of the left fistula

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 » Discussion Top

For sequential occlusion and for planning of the venous approach, the drainage system of DAVFs must be carefully analyzed with respect to the drainage of the brain and anatomic variants. [5] When catheterization is possible, transvenous embolization is associated with a high rate of permanent long-term occlusion. [16],[17] Occlusion can be achieved with placement of coils, via a trans-sinusoidal route, in the venous channel of a DAVF outside the sinus lumen [5],[14],[18],[19] or occlusion of the involved sinus segment.

We have used a new liquid embolic agent (Onyx) for embolization of dural fistulas of the cavernous sinus. Its nonadhesive and cohesive properties make this agent suitable for transvenous casting of the cavernous sinus. [8],[20],[21] The Guglielmi detachable coils (GDC) are more expensive and less thromobogenic than the platinum mirocoils. To achieve complete occlusion, the cavernous sinus was tightly packed with GDCs. This tight packing may account for the intense nausea, vomiting and third or sixth cranial nerve palsy following coil embolization. [22],[23] However, our patients did not develop a new cranial nerve palsy. There was no recanalization at 7-month control grams, and the embolic agent was safe and permanent. In our patients, inappropriate occlusion of the draining vein did not occur and we achieved a good clinical outcome. From this point of view, we prefer to use platinum coils and Onyx because of their radiological opacity and controllable characteristics. Detachable platinum coils and Onyx-34 were used during the venous approach in case of high-flow cavernous DAVFs. Onyx injection was performed into a basket of coils. In this situation, distal migration of glue to the ophthalmic vein can be avoided. If the tip of the microcatheter reached the fistula point, Onyx injection can also be performed without delivery of platinum coils. If Onyx migration was found under biplane roadmapping, the injection was stopped, waiting for the solidification of Onyx. Then, the injection was continued to pack the cavernous sinus. The complex nature of the fistula, the unexpected hardship in the placement of detachable coils and our previous experience with Onyx in the treatment of DAVFs promoted us to use Onyx in the treatment of our patient. [8],[20],[21],[24],[25] The slow injection of the agent might have been the key factor that enabled gradual casting of the sinus, with filling of its interstices and blocking of the minute fistulous communications. During the intracavernous injection of the embolic agent, caution was exerted to avoid inadvertent embolization of the left internal carotid artery during the slow injection of Onyx.

Reflex bradycardia occurred in two patients. This was blocked with atropine, and did not recur. Trigemocardiac reflex may be related to irritation of the trigeminal ganglion or afferent fibers within the cavernous sinus, respectively, by DMSO injection, Onyx formation or sudden change in venous hemodynamics during the embolization procedure. Specifically, as the reflex occurred during the initial phase of our transvenous embolization, it is unlikely that the Onyx mass itself compressed the division of the trigeminal nerve. [26] It is most likely that some sort of chemical irritation might have resulted. The other concern could have been the potential neurotoxity of DMSO on the trigeminal cranial nerve within the cavernous sinus. We speculate that a slow rate of injection may give DMSO enough time to dissipate in the blood stream, and may prevent the toxic effects. [8],[20],[21]

 » References Top

1.Leonard F, Jeffrey B, Nicholas JV. Cavernous sinus fistulas: Carotid cavernous fistulas and dural arteriovenous malformations. Curr Neurol Neurosci Rep 2003;3:415-20.  Back to cited text no. 1
2.Benndorf G, Bender A, Lehmann R, Lanksch W. Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: Report of four cases and review of the literature. Surg Neurol 2000;54:42-54.   Back to cited text no. 2
3.Liu HM, Huang YC, Wang YH, Tu YK. Transarterial embolization of complex cavernous sinus dural arteriovenous fistulae with low-concentration cyanoacrylate. Neuroradiology 2000;42:766-70.  Back to cited text no. 3
4.Nakamura M, Tamaki N, Kawaguchi T, Fujita S. Selective transvenous embolization of dural carotid-cavernous sinus fistulas with preservation of sylvian venous outflow. Report of three cases. J Neurosurg 1998;89:825-9  Back to cited text no. 4
5.Roy D, Raymond J. The role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas. Neurosurgery 1997;40:1133-44.  Back to cited text no. 5
6.Satomci J, Satoh K, Matsubara S, Nakajima N, Nagahiro S. Angiographic changes in venous drainage of cavernous sinus dural arteriovenous fistulae after palliative transarterial embolization or observational management: A proposed stage classification. Neurosurgery 2005;56:494-502.  Back to cited text no. 6
7.Kuwayama N, Endo S, Kitabayashi M, Nishijima M, Takaku A. Surgical transvenous embolization of a cortically draining carotid cavernous fistula via a vein of the sylvian fissure. AJNR Am J Neuroradiol 1998;19:1329-32.  Back to cited text no. 7
8.Suzuki S, Lee DW, Jahan R, Duckwiler GR, Vinuela F. Transvenous treatment of spontaneous dural carotid-cavernous fistulas using a combination of detachable coils and Onyx. AJNR Am J Neuroradiol 2006;27:1346-9.  Back to cited text no. 8
9.Tu YK, Liu HM, Hu SC. Direct surgery of carotid cavernous fistulae and dural arteriovenous malformations of the cavernous sinus. Neurosurgery 1997;41:798-806.  Back to cited text no. 9
10.Bruce EP, Douglas AN, James AG, Deborah AG, Scott LS. Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae. Neurosurgery 1999;45:459-66.  Back to cited text no. 10
11.Kazekawa K, Iko M, Sakamoto S, Aikawa H, Tsutsumi M, Kodama T, et al. Dural AVFs of the cavernous sinus: Transvenous embolization using a direct superficial temporal vein approach. Radiation Medicine 2003;21:138-41.  Back to cited text no. 11
12.Krisht AF, Burson T. Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: Technical case report. Neurosurgery 1999;44:415-8.  Back to cited text no. 12
13.Kai Y, Hamada J, Morioka M, Yano S, Kuratsu J Treatment of cavernous sinus dural arteriovenous fistulae by external manual carotid compression. Neurosurgery 2007;60:253-8.  Back to cited text no. 13
14.Urtasun F, Biondi A, Casaco A, Houdart E, Caputo N, Aymard A, et al. Cerebral dural arteriovenous fistulas: Percutaneous transvenous embolization. Radiology 1996;199:209-17.  Back to cited text no. 14
15.Kim DJ, Kim DI, Suh SH, Kim J, Lee SK, Kim EY, et al. Results of transvenous embolization of cavernous dural arteriovenous fistula: A single-center experience with emphasis on complications and management. AJNR Am J Neuroradiol 2006;27:2078-82.  Back to cited text no. 15
16.Quinones D, Duckwiler G, Gobin PY, Goldberg RA, Vinuela F. Embolization of dural cavernous fistulas via superior ophthalmic vein approach. AJNR Am J Neuroradiol 1997;18:921-8.  Back to cited text no. 16
17.Klisch J, Huppertz HJ, Spetzger U, Hetzel A, Seeger W, Schumacher M. Transvenous treatment of carotid cavernous and dural arteriovenous fistulae: Results for 31 patients and review of the literature. Neurosurgery 2003;53:836-57.  Back to cited text no. 17
18.Goldberg RA, Goldey SH, Duckwiler G, Vineula F. Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein. Arch Ophthamol 1997;115:823-4.  Back to cited text no. 18
19.Jahan R, Gobin YP, Glenn B, Duckwiler GR, Vinuela F. Transvenous embolization of a dural arteriovenous fistula of the cavernous sinus through the contralateral pterygoid plexus. Neuroradiology 1998;40:189-93.  Back to cited text no. 19
20.Arat A, Cekirge S, Saatci I, Ozgen B. Transvenous injection of Onyx for casting of the cavernous sinus for the treatment of a carotid-cavernous fistula. Neuroradiology 2004;46:1012-5.  Back to cited text no. 20
21.Jiang CH, Lv XL, Li YX, Liu AH, Lv M, Jiang P, et al. Transvenous embolization of cavernous sinus dural arteriovenous fistula with Onyx-18 and plentinum coils: Technical Note. Neuroradiol J 2007;20:47-52.  Back to cited text no. 21
22.Aihara N, Mase M, Yamada K, Barno T, Watanake K, Kamiya K, et al. Deterioration of ocular motor dysfunction after transvenous embolization of dural arteriovenous fistula involving the cavernous sinus. Acta Neurochir 1999;141:707-10.  Back to cited text no. 22
23.Oishi H, Arai H, Sato K, Iizuka Y. Complications associated with transvenous embolization of cavernous dural arteriovenous fistula. Acta Neurochir 1999;141:1265-71.  Back to cited text no. 23
24.Lv X, Li Y, Liu A, Jiang C, Wu Z. Transarterial embolization of dural arteriovenous fistulas of the anterior cranial fossa Onyx-18: Case report. Neuroradiol J 2007;20:53-9.  Back to cited text no. 24
25.Toulgoat F, Mounayer C, Tulio Salles Rezende M, Piotin M, Spelle L, Lazzarotti G, et al. Transarterial embolization of intracranial dural arteriovenous malformations with ethylene vinyl alcohol copolymer(Onyx-18). J Neuroradiol 2006;33:105-14.  Back to cited text no. 25
26.Lv X, Li Y, Lv M, Liu A, Zhang J, Wu Z. Trigeminocardiac reflex in embolization of intracranial dural arteriovenous fistula. AJNR Am J Neuroradiol 2007;28:1769-70.  Back to cited text no. 26


  [Figure 1]

  [Table 1]

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