• Lukas Goertz, Ludwig M Heindl, Franziska Dorn, Marc Schlamann, and Christoph Kabbasch.
• Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany. Electronic address: lukas.goertz@uk-koeln.de.
• World Neurosurg. 2023 Jul 1; 175: 121612-16.

ObjectiveWe describe our rescue technique for direct puncture of the inferior ophthalmic vein (IOV) for transvenous access of a direct, high-flow carotid-cavernous fistula (CCF).MethodsThe CCF was caused by rupture of a large internal carotid artery aneurysm. Aneurysm and fistula embolization solely via the transarterial approach did not appear promising due to partial aneurysm thrombosis. Also, transvenous access via the facial vein failed due to extensive vessel tortuosity. Instead, the engorged and arterialized IOV was accessed by direct puncture with an 18-gauge venous cannula. After a small skin incision of the medial aspect of the lower eyelid and further transseptal puncture, the cannula was advanced stepwise between the maxillary bone and the bulbus oculi and below the medial rectus muscle to the IOV under repeated biplane roadmap guidance in 2 planes. Thereafter, the fistula and the aneurysm dome could be embolized with coils via a low-profile microcatheter. Hereby, a protective flow diverter was implanted via the arterial route into the internal carotid artery to seal the parent artery, prevent coil protrusion, and ensure permanent aneurysm occlusion.ResultsAt 1-month follow-up, the aneurysm and CCF were completely occluded.ConclusionsDirect puncture of the IOV represents a feasible and minimally invasive approach for venous CCF access. The proposed method needs to be validated by further reports.Copyright © 2023 Elsevier Inc. All rights reserved.

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