Operative approach via the superior ophthalmic vein for the endovascular treatment of carotid cavernous fistulas that fail traditional endovascular access.

Endovascular embolization is the preferred treatment for carotid-cavernous fistulas (CCFs), but failure to catheterize the cavernous sinus may occur as a result of tortuosity, hypoplasia, or stenosis of the normal venous routes. In these cases, direct operative cannulation of the arterialized superior ophthalmic vein (SOV) offers an excellent alternative approach. We reviewed the records of patients who underwent surgical cannulation of the SOV in preparation for embolization and identified 10 patients with indirect CCF, all of whom presented with ocular signs and symptoms. All had previously undergone unsuccessful endovenous attempts at treatment at our institution. In the operating room, the SOV was catheterized under microscopic magnification through an eyelid or eyebrow incision, and the patients were taken directly to the angiographic suite for embolization. In 9 of 10 patients, embolization of the CCF was complete with clinical improvement. In 1 case, navigation of the catheter into the SOV proved difficult, and the procedure was aborted because of contrast extravasation after partial embolization. One patient required a small orbital osteotomy to localize the SOV. There were no clinical complications and no known recurrences. Cosmetic results were excellent in all patients. Surgical access to the superior ophthalmic vein for embolization of a CCF is an excellent and definitive alternative treatment when traditional endovenous routes are inaccessible. The operative approach to the SOV is straightforward and can be performed safely and expeditiously by the neurovascular team.