Journal of Neuroradiology (2012) 39, 181—185 CASE REPORT Embolization of carotid-cavernous fistula via direct percutaneous puncture of the inferior ophthalmic vein Embolisation d’une fistule carotido-caverneuse après ponction directe percutanée de la veine ophtalmique inférieure Michelle M. Cecchini a,* , Michael R. Levitt a , Manish Taneja b , Danial K. Hallam a,b , Basavaraj V. Ghodke a,b a Box 359924, Department of Neurological Surgery, University of Washington and Harborview Medical Center, 1959 NE Pacific Street, Seattle, WA 98195, USA b Department of Radiology, University of Washington and Harborview Medical Center, 1959 NE Pacific Street, Seattle, WA 98195, USA KEYWORDS Carotid-cavernous sinus fistula; Therapeutic embolization; Inferior ophthalmic vein Summary Carotid-cavernous fistulas (CCFs) are anomalous connections between the carotid circulation and the cavernous sinus, and may cause significant morbidity. Endovascular treat- ment of these lesions can be challenging if typical transvenous routes are inaccessible. We describe a case of a Barrow type D carotid-cavernous fistula in which transvenous embolization was attempted via the inferior petrosal sinus (IPS). No connection was found to the fistula, and the superior ophthalmic vein (SOV) was thrombosed. A novel direct percutaneous puncture of the IOV was performed with ultrasound guidance showing that this is a safe alternative route of CCF access and embolization when the IPS and SOV are inaccessible. Published by Elsevier Masson SAS. Introduction Carotid-cavernous fistulas (CCFs) are abnormal connections between the external carotid artery (ECA) and/or internal carotid artery (ICA) and the cavernous sinus. They have been categorized by the Barrow Classification as direct (Type A) or indirect fistulae, with the latter category * Corresponding author. Tel.: +206 543 3570; fax: +206 543 8315. E-mail address: mcecch@u.washington.edu (M.M. Cecchini). subdivided by arterial supply from the ICA (Type B), ECA (Type C), or a combination of both (Type D) [1]. While direct fistulas may be treated transarterially [2], indirect fistulas are commonly treated through a transvenous approach, as transarterial embolization is difficult due to multiple small arterial feeders. The transvenous approach to the cavernous sinus requires catheterization of the inferior petrosal sinus (IPS) or, when that is inaccessible or disconnected from the fistula, the superior ophthalmic vein (SOV). There have been several reports of direct transorbital puncture of the cavernous sinus [3—7] as well as two reports of surgical cutdown access to the inferior ophthalmic vein (IOV) [8,9] 0150-9861/$ – see front matter. Published by Elsevier Masson SAS. doi:10.1016/j.neurad.2011.05.007