BACKGROUND AND IMPORTANCE: Many techniques for accessing the cavernous sinus have been described, from a transfemoral venous approach to a direct surgical exposure and cannulation of the superior ophthalmic vein. The cavernous sinus can be accessed safely through direct transorbital puncture and cannulation of a preceding venous confluence with an 18-gauge angiocatheter. This technique is performed under constant fluoroscopy using bony landmarks. The use of XperGuide software allows the operator to obtain an intraprocedural computed tomography and to identify the optimum needle entry point and trajectory to avoid at-risk structures such as the optic nerve in this case. This trajectory is then superimposed onto the real-time fluoroscopic image, and the guidance trajectory is followed during needle insertion. CLINICAL PRESENTATION: The patient is a 66-year-old woman who spontaneously developed a left-sided cavernous sinus syndrome. She was found to have an indirect carotid cavernous fistula on angiography. Because of tortuosity and occlusion of venous access points to the cavernous sinus, access via transorbital puncture was preferred. The XperGuide system was used to avoid the at-risk structures, and coils were safely deployed within the cavernous sinus after successful cannulation with this guidance system. The patient had complete resolution of her fistula and experienced no complications from the procedure. CONCLUSION: The XperGuide software guidance system is helpful during direct transorbital puncture of the cavernous sinus because it allows better monitoring of real-time needle location along a safe trajectory selected by the operator to avoid damaging local soft tissue structures.
BACKGROUND AND IMPORTANCE: Many techniques for accessing the cavernous sinus have been described, from a transfemoral venous approach to a direct surgical exposure and cannulation of the superior ophthalmic vein. The cavernous sinus can be accessed safely through direct transorbital puncture and cannulation of a preceding venous confluence with an 18-gauge angiocatheter. This technique is performed under constant fluoroscopy using bony landmarks. The use of XperGuide software allows the operator to obtain an intraprocedural computed tomography and to identify the optimum needle entry point and trajectory to avoid at-risk structures such as the optic nerve in this case. This trajectory is then superimposed onto the real-time fluoroscopic image, and the guidance trajectory is followed during needle insertion. CLINICAL PRESENTATION: The patient is a 66-year-old woman who spontaneously developed a left-sided cavernous sinus syndrome. She was found to have an indirect carotid cavernous fistula on angiography. Because of tortuosity and occlusion of venous access points to the cavernous sinus, access via transorbital puncture was preferred. The XperGuide system was used to avoid the at-risk structures, and coils were safely deployed within the cavernous sinus after successful cannulation with this guidance system. The patient had complete resolution of her fistula and experienced no complications from the procedure. CONCLUSION: The XperGuide software guidance system is helpful during direct transorbital puncture of the cavernous sinus because it allows better monitoring of real-time needle location along a safe trajectory selected by the operator to avoid damaging local soft tissue structures.
Authors: Ching-Jen Chen; Panagiotis Mastorakos; James P Caruso; Dale Ding; Paul J Schmitt; Thomas J Buell; Daniel M Raper; Avery Evans; Steven A Newman; Mary E Jensen Journal: Cureus Date: 2017-01-12