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Anteroposterior left internal carotid artery (a) and external carotid artery (b) digital subtraction angiogram views demonstrating the indirect carotid cavernous fistula (CCF). Antero-posterior (c) and lateral (d) views of the left internal carotid artery digital subtraction angiogram demonstrating complete occlusion of the CCF d c
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... There are alternative transfemoral venous routes such as the superior petrosal sinus and superior ophthalmic vein. More invasive approaches such as direct transorbital puncture or surgery can also be performed in rare circumstances, but these may increase patient comorbidity 3,6,11,24,26,27) . ...
Objective:
Transvenous embolization (TVE) via an occluded inferior petrosal sinus (IPS) in a cavernous sinus dural arteriovenous fistula (CSDAVF) is challenging, often requiring navigation of a microcatheter through resistive obstacles between the occluded IPS and shunted pouch (SP), although the reopening technique was successfully performed. We report five cases of successful access to the cavernous sinus (CS) or SP using the rigid-tipped microguidewire such as chronic total occlusion (CTO) wire aiming to share our initial experience with this wire.
Methods:
In this retrospective study, four patients with CSDAVF underwent five procedures using the CTO wire puncture during transfemoral transvenous coil embolization. Puncture success, shunt occlusion, and complications including any hemorrhage and cranial nerve palsy were evaluated.
Results:
Despite successful access through the occluded IPS, further entry into the target area using neurointerventional devices was impossible due to a short-segment stricture before the CS (three cases) and a membranous barrier within the CS (two cases). However, puncturing these structures using the rigid-tipped microguidewire was successful in all cases. We could advance the microcatheter over the rigid-tipped microguidewire for the navigation to the SP and achieved complete occlusion of the SP without complications.
Conclusion:
The use of the rigid-tipped microguidewire in the TVE via the occluded IPS of the CSDAVF would be feasible and safe.
... The ISAT (International Subarachnoid Aneurysm Trial) requires subjective agreement that an aneurysm might be treated by endovascular or open surgery (5). Many aneurysms, however, did not fit the requirements, such as: 1-patients with lifethreatening intracerebral or subdural hematomas; 2-incompatible neck-to-dome ratios; 3-parent artery or branch artery incorporation into the dome; 4fusiform aneurysms; 5-thrombotic aneurysms; 6giants; 7-blisters; 8-pseudo/traumatic aneurysms; 9those with mass effect; and 10-those that had failed repeated endovascular treatment (16,20). ...
... (14,17) Other case reports were documented in the literature too. (5,7,9,13) A furthermore studies are expected be conducted on a larger scale concerning the hybrid cerebrovascular surgery in the nearby future. ...
Background: The main treatment of cerebral aneurysms is direct surgical clipping or endovascular coil embolization. However, some cerebral aneurysms that we reviewed in the literature are still not susceptible to a single treatment approach. These aneurysms can be referred to as complex aneurysms. Objective: We aim to report these aneurysms and share our clinical experience with their treatment and diagnosis. Methods: All cases of cerebral aneurysms treated in New York University and in Mansoura University from 2010-2021 were retrospectively reviewed. Results: 18 patients with 21 cerebral aneurysms were treated by combined surgical and endovascular modalities. Aneurysms associated with arteriovenous malformations (AVMs) in 3 patients, associated with vasospasm in 7 patients, and 3 patients had double aneurysms. A total of 18 patients with aneurysms were treated with combined endovascular and microsurgical therapy. Early angiogram (< 1 week) revealed; complete obliteration of 19 aneurysms (90%) out of a total of 21 aneurysms, residual filling was observed in 2 aneurysms (10%). Late radiological follow up (> 3 months- 2 years) revealed; a stable residual filling in one and the other case underwent retreatment. Conclusions: The recalcitrant or complex cerebral aneurysms can be better referred to as diseases rather than lesions as many clinical and anatomical factors make their treatment difficult. Endovascular and microsurgery could be complementary to each other and create a multimodal approach for treating them.
... 12 Rarely, direct surgical visualization of the CS is required and can be accomplished by craniotomy or via an endoscopic endonasal approach. 9,13,14 Multimodal Approach Considerations Select cases require multiple approaches to the CS to achieve complete obliteration of a fistula owing to inadequate initial embolization, recurrence in the setting of access occlusion from previous embolization, or complex fistula pouches requiring access to multiple CS compartments. A multimodal approach was performed in a single procedure in 2 patients in our series and is advantageous for several reasons. ...
