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Superior Ophthalmic Vein Cannulation Through a Lateral Orbitotomy for Embolization of a Cavernous Dural Fistula

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Superior Ophthalmic Vein Cannulation Through a Lateral Orbitotomy for Embolization of a Cavernous Dural Fistula SURGICAL TECHNIQUE Superior Ophthalmic Vein Cannulation Through a Lateral Orbitotomy for Embolization of a Cavernous Dural Fistula Jaime Badilla, MD; Charles Haw, MD, FRCSC; Jack Rootman, MD, FRCSC any embolization procedures have been described for the treatment of cavernous dural fistulas, including direct superior ophthalmic vein cannulation. Sometimes thrombosis of the superior ophthalmic vein or an anatomic variant will not allow its cannulation. Herein, we describe a case of a cavernous dural fistula in which an Manteriorly narrowed and thrombosed superior ophthalmic vein was cannulated in the deep orbit through a lateral orbitotomy. Arch Ophthalmol. 2007;125(12):1700-1702 Cavernous dural fistulas are usually em- amination results in the left eye were bolized through a transfemoral arterial or unremarkable. Computed tomographic an- venous approach. When these tech- giography demonstrated a prominent right niques fail, the possibility of emboliza- superior ophthalmic vein. Catheter angi- tion performed directly through the su- ography showed a cavernous dural arte- perior ophthalmic vein is a well-known riovenous fistula fed by dural branches of option. We present a technique via lat- the right internal and external carotid ar- eral orbitotomy, which is a useful option teries. The diagnosis of low-flow cavern- when the direct eyelid-crease approach to ous dural fistula, Barrow type D, was made. the superior ophthalmic vein fails. An attempt at transfemoral embolization through the inferior petrosal sinus was not CASE REPORT AND TECHNIQUE achieved owing to compartmentalization of the cavernous sinus. A facial vein ap- proach was attempted and was not suc- A 61-year-old man with known mitral cessful owing to tortuosity of the veins. The valve prolapse and no head trauma had a procedure was concluded at this point. 6-week history of acute-onset conjuncti- Two weeks later, the patient noticed de- val injection and pain in his right eye at creased vision in his right eye (visual acu- initial admission. Best-corrected visual acu- ity was 20/25 OD); he had an increased af- ity was 20/25 OD and 20/20 OS. Color vi- ferent pupillary defect due to a choroidal sion was normal with a mild afferent pu- effusion. We attempted to perform a di- pillary defect in the right eye. There was rect cannulation of the superior ophthal- 5 mm of proptosis in the right eye with a mic vein through an upper eyelid-crease 2-mm lateral displacement and resis- incision to introduce a coil. After expos- tance to retropulsion (Figure 1A). Right ing the superior ophthalmic vein, a 20- eye movement was slightly limited in up- gauge angiocatheter was used to punc- gaze and abduction. His intraocular pres- ture the vein and gain access to introduce sure was 18 mm Hg OD and 11 mm Hg the guide wire, which advanced for a few OS. Slitlamp examination revealed che- millimeters before there was some resis- mosis, dilated episcleral veins, and di- tance due to previously noticed narrow- lated retinal vessels in the right eye. Ex- ing. A second attempt was done more pos- Author Affiliations: Department of Ophthalmology and Visual Sciences terior in the superior ophthalmic vein and (Drs Badilla and Rootman), Department of Surgery, Division of Neurosurgery was again unsuccessful. The procedure was (Dr Haw), and Department of Pathology and Laboratory Medicine (Dr Rootman), aborted at this point. On the fifth day of University of British Columbia and the Vancouver General Hospital, Vancouver, follow-up, best-corrected visual acuity had Canada. decreased to 20/70 OD, and the fundus had (REPRINTED) ARCH OPHTHALMOL / VOL 125 (NO. 12), DEC 2007 WWW.ARCHOPHTHALMOL.COM 1700 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 noticeable intraretinal hemorrhage and congestion (Figures 1B and C). A Repeat computed tomographic angiography showed that the ante- rior portion of the superior ophthal- mic vein had thrombosed, prob- ably induced by the surgical manipulation (Figure 2A). A lat- eral orbital approach to reach the most posterior portion of the supe- rior ophthalmic vein within the or- B C bital apex was planned to achieve coiling. A superior eyelid-crease in- cision was made and extended tem- porally to expose the superior and lateral orbital rim. A superolateral marginectomy was performed. This allowed direct visualization of the su- perior orbital fissure. The perior- bita was then incised between the lat- eral and the superior rectus muscles. With blunt dissection through the orbital fat, an enlarged arterialized superior ophthalmic vein was found. D E A silk suture was passed around it. A pediatric 3F Check-Flo Per- former Introducer Set (Cook Medi- cal, Bloomington, Indiana) was used to cannulate the superior ophthal- mic vein, with the cannula’s distal tip near the entry point to the cav- ernous sinus; the silk suture was tied Figure 1. A, A 61-year-old man with a 6-week history of right-eye injection and 5 mm of proptosis. to stabilize the cannula. The orbital B, Right fundus examination 8 weeks after initial symptoms with tortuous, enlarged, venous temporal and rim was repositioned with 2 tita- nasal arcades; flame and dot-blot hemorrhages; blurred temporal optic nerve border; and a nium plates, and the incision was su- best-corrected visual acuity of 20/70 OD. C, Right eye late-phase fluorescein angiography showing congested veins and macular edema. D, Cannula into the superior ophthalmic vein after its placement. tured. The proximal end of the can- E, Four weeks postoperative follow-up showing resolution of conjunctival injection, 3-mm proptosis, and nula was fixed to the skin with a a best-corrected visual acuity of 20/20 OD. suture, and the patient, who was un- der general anesthesia, was then At the sixth day of follow-up, mic vein approach include when ar- transferred to the angiography unit best-corrected visual acuity was terial or transvenous approaches are (Figure 1D). Through a 5F sheath 20/40 OD, with reduction of the pa- not possible or fail to completely placed in the right common fem- tient’s hyperopic shift, 3 mm of pro- close the fistula, wanting to avoid oral artery, a diagnostic catheter was ptosis, and slight limitation of up- complications associated with oc- placed in the right internal and ex- gaze. His intraocular pressure was 10 clusion when there is predominant ternal carotid arteries and used for mm Hg OD. At 1 month of follow- internal carotid artery supply, and control injections (Figure 2B). In- up, his best-corrected visual acuity patients with atherosclerosis in jections through the 3F cannula was 20/20 OU, proptosis resolved whom carotid compression can be placed in the superior ophthalmic with mild residual limitation in up- contraindicated.4 The transcutane- vein demonstrated a persistently gaze in his right eye, and his intra- ous eyelid-crease approach to the su- patent dural fistula (Figure 2C). A ocular pressure was 10 mm Hg OD perior ophthalmic vein may have renegade microcatheter (Boston Sci- (Figure 1E). some difficulties, such as small veins, entific, Natick, Massachusetts) was variations in location of the supe- placed through the 3F cannula di- COMMENT rior ophthalmic vein, and clotting of rectly to the zone of arteriovenous the vein, which can make it impos- shunting. Thereafter, 3 Micron- When other options are not fea- sible to place the catheter.7 ester Coils (Cook Medical) were sible, embolization of a cavernous In this case, an eyelid-crease su- placed with dense packing in this dural fistula through the superior perior ophthalmic vein approach was area; the renegade catheter and the ophthalmic vein via an eyelid- performed after an unsuccessful per- 3F cannula were removed. Control crease incision has proven to be a cutaneous embolization attempt. injections confirmed cure of the fis- good procedure.1-6 Some indica- During the surgical procedure, the tula (Figure 2D). tions for a direct superior ophthal- cannulation was impossible owing (REPRINTED) ARCH OPHTHALMOL / VOL 125 (NO. 12), DEC 2007 WWW.ARCHOPHTHALMOL.COM 1701 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 tion associated with an eyelid- A B crease approach (without bone re- moval) to the posterior superior ophthalmic vein. Thus, it reduces the risks of uncontrolled bleeding and damage to structures during deep or- bit dissection. To our knowledge, this is the first time a lateral orbital wall removal was performed to cannulate the superior ophthalmic vein. This ap- proach is best performed in medi- cal centers where experienced in- terventional neuroradiologist and orbital surgeons have developed a C D cooperative team. Submitted for Publication: June 20, 2007; final revision received Au- gust 29, 2007; accepted August 30, 2007. Correspondence: Jack Rootman, MD, FRCSC, University of British Columbia, Eye Care Centre, 2550 Willow St, Vancouver, BC V5Z 3N9, Canada ([email protected] .ca). Financial Disclosure: None re- ported. Figure 2. A, Axial computed tomographic angiography showing a thrombosed anterior portion of right superior ophthalmic vein (arrow). B, Lateral angiogram of internal carotid artery before coiling showing an enlarged superior ophthalmic vein (small arrow) and the cavernous dural fistula (large arrow). REFERENCES C, Direct contrast injection through the venous catheter indicating the site of the fistula (arrow). D, Lateral angiography of the internal carotid artery after the coiling showing the coils (arrow) obliterating the fistula 1. Hanneken AM, Miller NR, Debrun GM, Nauta HJ. site and blocking the shunt to the superior ophthalmic vein. Treatment of carotid-cavernous sinus fistulas using a detachable balloon catheter through the supe- to stenosis of the superior ophthal- as it enters the superior orbital fis- rior ophthalmic vein. Arch Ophthalmol. 1989;107 mic vein and a more posterior at- sure.
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