Cavernous sinus dural arteriovenous fistula accessed through a straightened superficial temporal vein

Background: Transvenous embolization through the inferior petrosal sinus (IPS) is the most common treatment procedure for cavernous sinus dural arteriovenous fistula (CSDAVF). When the IPS is inaccessible or the CSDAVF cannot be treated with transvenous embolization through the IPS, the superficial temporal vein (STV) is used as an alternative access route. However, the approach through the STV is often challenging because of its tortuous and abruptly angulated course. We report a case of recurrent CSDAVF which was successfully treated using a chronic total occlusion (CTO)-dedicated guidewire and by straightening the STV.

Case description: A 63-year-old woman was diagnosed with CSDAVF on examination for oculomotor and abducens nerve palsy. She was initially treated with transvenous embolization through the IPS. However, CSDAVF recurred, and transvenous embolization was performed through the STV. A microcatheter could not be navigated because of the highly meandering access route through the STV. By inserting a CTO-dedicated guidewire into the microcatheter, the STV was straightened and the microcatheter could be navigated into a shunted pouch of the CS. Finally, complete occlusion of the CSDAVF was achieved.

Conclusion: If an access route is highly meandering, the approach can be facilitated by straightening the access route with a CTO-dedicated guidewire.