Introduction
: Cavernous sinus (CS) via inferior petrosal sinus (IPS) access can present a challenge in the treatment of carotid‐cavernous fistulas (CCF) due to anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection.
Methods
: A 58‐year‐old male was referred to our academic medical center for three weeks of right eye pain, now complicated by redness, diplopia and blurry vision. Magnetic Resonance Imaging (MRI) brain at the outside hospital revealed hemorrhagic lesion in right parietotemporal region. Computerized tomography‐angiogram (CTA) of the head revealed filling of cavernous sinus during an arterial phase suspicious for CCF. Under general anesthesia, after accessing right common femoral artery, 4 French (F) cook catheter (Cook Medical LLC, Bloomington, IN) was advanced over 0.035 angled glide wire to the proximal right internal carotid artery. Contrast injected through the ICA showed the CS but not the IPS (Fig. 1A). Through the left common femoral vein, access was obtained using an Infinity guide catheter (Stryker Neurovascular, Fremont, CA) and Catalyst 5 (Stryker Neurovascular, Fremont, CA) distal access catheter. A Synchro 2 soft microwire (Stryker Neurovascular, Fremont, CA) was advanced through Echelon 10 (Medtronic, Minneapolis, MN) microcatheter. The venous guide catheter was advanced into right internal jugular vein (IJV) and the distal access catheter was placed into sigmoid jugular junction. Injection of contrast revealed the IPS, but not the CS (Fig. 1B). A subsequent simultaneous hand injection with the microcatheter within the IPS and the diagnostic catheter in the left ICA elucidated the venous‐venous connection (Fig. 1C,) allowing for subsequent navigation and complete treatment of the fistula through IPS using target coils (Fig. 1D).
Results
: Given the arterial system is a high‐pressure system and the usual direction of flow of contrast would be from the high‐pressure ICA to the low‐pressure CS, injecting a simultaneous contrast bolus from the venous end would oppose the arterial contrast flow. As a result, the fistulous connection that was previously obscured became visible allowing roadmap imaging guiding navigation into the CS.
Conclusions
: Use of simultaneous trans‐arterial/trans‐venous contrast injection is relatively simple compared to other reported techniques to reveal an obscure connection point. It also shortens the duration of endovascular tools in the bloodstream and thus, reduces the potential complication rate. Further use of this technique on larger study samples is important to validate its general use.
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