EMBOLIZATION OF DURAL ARTERIOVENOUS FISTULA
P. Pearse Morris, M.B., B.Ch.
INSTITUTION: Wake Forest University Baptist Medical Center
DESCRIPTION OF PROCEDURE: Embolization of dural arteriovenous
fistula (indirect carotid cavernous fistula)
DATE OF PROCEDURE: September 27, 2001
PRESENTING SYMPTOMS: Redness, chemosis, and proptosis
of the right eye
THERAPEUTIC OBJECTIVES:
Pack right cavernous sinus with thrombogenic coils
DESCRIPTION OF PROCEDURE:
An arterial catheter was placed in the ipsilateral carotid artery
for road map imaging and monitoring of the progress of the case.
A second venous catheter was placed in the ipsilateral jugular
bulb. A Renegade microcatheter was placed over a SYNCHRO™
Neuro Guide Wire at the back of the superior ophthalmic vein,
and used to deliver thrombogenic coils to the desired location.
OBSERVATIONS ON GUIDE WIRE PERFORMANCE:
The initial injection of the right common carotid artery (A) shows
early opacification of the ipsilateral cavernous sinus (single
arrow), the ipsilateral inferior petrosal sinus (double arrowhead),
and the ipsilateral jugular vein (double arrow). Using this venous
route of access to the cavernous sinus, a Renegade microcatheter
was steered retrogradely to the cavernous sinus, where a contrast
injection was performed (B). The microcatheter position (arrow
in B) within the cavernous sinus was not sufficiently advanced
at this stage to allow definitive occlusion of the dural AVM.
For complete obliteration of the dAVM, it was necessary to advance
the microcatheter to the junction between the superior ophthalmic
vein and the anterior aspect of the cavernous sinus (arrowhead
in B). A variety of wires from a number of vendors were used for
this, but the downward turn from the main pocket of the cavernous
sinus into one of the two channels connecting the SOV with the
cavernous sinus, followed by the need for an immediate anterior
turn into the more distal SOV, proved too challenging for all
typical wires used that day. The SYNCHRO wire made this maneuver
on its first attempt, smoothly negotiating the chicane of the
channel and easily accessing the more distal SOV, giving adequate
support for the Renegade microcatheter to follow. Post-embolization
images of the right carotid artery (C subtracted) show immediate
elimination of fistulous venous flow. A non-subtracted right carotid
injection (D) shows the disposition of coils within the cavernous
sinus, with the arrow pointing at the most critical set of coils
in the junction between the SOV and cavernous sinus. The atraumatic
steerability of the SYNCHRO wire in this and other difficult cases
has been most impressive, placing this wire in a category unto
itself in my opinion.
LIST OF DEVICES USED:
0.014" SYNCHRO™ Neuro Guide Wire Model 1301, Precision Vascular
Systems, Inc.
Renegade™ 18 Microcatheter, Boston Scientific/Target
WLT0106/A
