Micrus Coil Embolization of a Cavernous Sinus Dural Arteriovenous Fistula Through the Facial Vein: Case Report

A 57-year-old man was referred to our hospital for detailed investigation and therapy of right exophthalmos and chemosis. Cerebral angiography demonstrated a dural arteriovenous fistula (DAVF) involving an anterior part of the right cavernous sinus (CS). The main feeders of the CS-DAVF consisted of the right inferolateral trunk and right middle meningeal artery. The predominant drainage route was the right superior ophthalmic vein (SOV), extending to the right facial vein. The right inferior petrosal sinus (IPS) was not visualized in the arterial phase, but was visualized in the venous phase, indicating that it contributes normal venous drainage. Transvenous embolization (TVE) was performed under general anesthesia through the right facial vein. We advanced a guiding catheter in the right angular vein and passed a microcatheter system through the tortuous vessel to the shunting point under single plane road mapping. The affected anterior part of the CS was occluded with Micrus coils (UltiPaq and Cashmere) (Micrus Endovascular, San Jose, CA, USA). Post-treatment angiography revealed disappearance of the fistula. In general, CS-DAVFs are treated with TVE through the IPS. However, in the present case, IPS was not used for the approach based on the angiographic appearance. Large drainage volume of the right facial vein enabled us to advance the guiding catheter to the angular vein with facility, and to pass the microcatheter system through the tortuous vessel with sufficient support of the guiding catheter. Cashmere, which is a 14 system infinity loop-shaped coil and relatively soft as a framing coil, had a tendency to attach to the anterior part of the CS wall. Because of good packing efficiency, transvenous Micrus coil embolization through the facial vein is an efficient treatment of DAVF involving the anterior part of the CS.