Severe trauma, with large direct CC fistula
BTO is a failure
The Papyrus covered stent was used. Delivered with aid of Navien 058 — the surest way to deliver this relatively stiff stent (still least stiff of all covered stents that could be used in the head) is to put a stiff intermediate catheter like the navien past the landing zone, advance stent to desired position, and pull back on the intermediate. Note the degree to which the cavernous segment is straightened.
Small residual fistula. The stent is typically overdilated by about 0.5 mm to achieve optimal results. This was a 4.5 dilated to a 5
What’s not too like?
This is what’s not to like. What’s happening here?
What is happening and why? How could this have been dealt with better? Is this coil likely to work?
A few weeks later… Orbital pressures are rising again
What’s happened?
Look at something very interesting below. In none of the above runs did we see an IPS. However, they are there — and quite large. Revealed by transvenous catheterization. Why would we not see them from arterial injections? Ultimately, trans-IPS approach to the CC failed
The least bad option at this point is a direct transorbital stick. Problem is this patient is on aspirin and brilinta because of the Papyrus.
Arrows point to target at the orbital apex / confluence of the superior and inferior fissures
Standard approach — 18 gauge 3.5 inch spinal needle advanced from inferolateral approach along the orbital floor
Note that the stylet is removed as we approach the target — the way to know you are there is by appropriately brisk blood return.
The needle is stabilized by the soft tissues and is gently attached to a heparinized saline pressure line. Gentle injection shows you are home
The rest is usually not very complex. An 018 catheter fits into the 18 gauge needle and is navigated where-ever needed, followed by coil and onyx occlusion. DMSO is likely not an issue. Notice how the microcatheter is looped in the sinus (top right picture). This is good for making sure the coil pack is tight and catheter does not get kicked out.
Final
See other Direct Puncture cases on Case Library Page
