Unusual Course of the Facial Vein Encountered during Direct Carotid Cavernous Fistula Embolization

Background: Transvenous embolization of a carotid-cavernous fistula is highly effective. The inferior petrosal sinus, the superior ophthalmic vein and even the pterygoid plexus are all possible routes to reach the fistula. Detailed knowledge of these venous channels anatomy is essential for successful treatment.

Case: A 66-year-old woman presented to the ophthalmologist with 3 days history of left eyelid swelling, exophthalmos, chemosis and corkscrew hyperemia. Periorbital bruit was audible on the left side. MRI/MRA showed dilation of the left superior ophthalmic vein and expansion of the left cavernous sinus. DSA images raveled a direct, high-flow left carotid-cavernous fistula. The right internal carotid filled the anterior circulation bilaterally. Transarterial and transvenous coiling (through the inferior petrosal sinus and the left superior ophthalmic vein) succeeded in closing the fistula and restoring the left anterior circulation. The unusual termination of the left common facial vein into the left subclavian vein was noted, it was used to gain access into the left superior ophthalmic vein.

Discussion: CCF can be embolized transvenously. The head and neck veins are endovascular routes for various vascular pathologies. In this case, the patient was spared a cutdown transpalpebral approach to the superior ophthalmic vein by tracing the common facial vein from its unusual subclavian vein termination.

Publication History

Article published online:
09 February 2023