Imaging-Guided Superior Ophthalmic Vein Access for Embolization of Dural Carotid Cavernous Fistulas: Report of 20 Cases and Review of the Literature

dCCF of the right cavernous sinus in a 56-year-old woman. A, Lateral-view angiogram from the right external carotid artery, obtained before embolization, shows a dCCF. The inferior petrosal sinus is thrombosed at the level of its inferior portion. There is predominant venous drainage toward the SOV (arrow). B, Direct percutaneous sonographically guided SOV puncture with a 22- or 24-ga angiocatheter cannula (arrow) using a high-frequency 15- to 7-MHz hockey stick sonography probe. C, Lateral-view roadmap, obtained after injecting the right external carotid artery, shows how a Transend 0.014-inch guidewire is advanced to the posterior aspect of the cavernous sinus. This allows subsequent exchange of a 2F inner for a 4F outer piece of a micropuncture set over a V-18 guidewire. D, Connecting system of two 30-cm connecting tubes and a Tuohy Borst hemostatic valve, which is connected to the micropuncture cannula. E, Lateral-view angiogram from the right external carotid artery shows the location in the posterior part of the cavernous sinus where a PX Slim microcatheter is placed (arrow). F, Lateral subtracted-view angiogram from the right external carotid artery shows how the coils are placed from posterior to anterior. G, Lateral blank subtraction roadmap demonstrating Gelfoam embolization of SOV from downstream to upstream while withdrawing the micropuncture cannula.