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PubMed1999

Mural aortic thrombi: An important cause of peripheral embolization.

PURPOSE: Arterial thromboembolism in patients with an unknown source of embolization is still associated with significant morbidity and mortality. The advent of transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) and the more frequent use of computed tomography (CT) have led to the identification of mural aortic thrombi (MAT) as a source of distal embolization in a much higher proportion of patients than previously appreciated. The incidence, diagnosis, and treatment of patients with MAT is reported. METHODS: In a prospective study, from January 1996 to December 1998, 89 patients with acute embolic events underwent an extensive diagnostic workup, consisting of TEE, CT, or MRI, to detect the source of embolization. Patients in whom the heart (n = 51), occlusive aortoiliac disease (n = 16), or aortic aneurysms (n = 12) was identified as the source of embolization were excluded. RESULTS: Five female and three male patients, with a median age of 63 years (range, 35 to 76 years), with bilateral or repetitive embolic events resulting from MAT were identified, representing 9% of all patients with arterial thrombembolism. All patients had several risk factors for atherosclerosis, but only one young patient had a single risk factor that promoted thrombosis. Successful percutaneous catheter aspiration embolectomy was performed in six patients. The remaining two patients underwent surgical thromboembolectomy. A below-knee amputation had to be performed in two patients, thus representing a morbidity of the primary treatment of 25%. MAT of equal value were detected in the ascending (n = 1) and thoracic aorta (n = 3) by means of TEE, CT, or MRI. MAT in the abdominal aorta (n = 4) were identified by means of CT and MRI. Surgical removal of MAT was performed in seven patients by means of graft replacement of the ascending aorta (n = 1), open thrombectomy of the descending aorta (n = 2), and thrombendarterectomy of the abdominal aorta (n = 4), without intraoperative or postoperative complications. No recurrence of MAT occurred during a median follow-up period of 13 months (range, 4 to 24 months). CONCLUSION: MAT represent an important source of arterial thrombembolism. A diagnostic workup of the aorta, preferably by means of CT or MRI, should be performed in all patients in whom other sources of embolization have been ruled out. The ideal therapeutic approach to these patients still awaits prospective evaluation. However, based on our experience, MAT can be successfully treated with a definitive surgical procedure in selected patients, with low mortality and morbidity.

Adult↗
PubMed1988

Paradoxical embolism after amputation in a newly diagnosed diabetic.

Paradoxical embolism is rare, but it should be considered in cases of (1) postoperative arterial or cerebral embolism, (2) pulmonary embolism accompanied by systemic arterial or cerebral embolism, (3) systemic arterial or cerebral embolism in patients with a known right-to-left shunt or pulmonary arteriovenous malformation, and (4) systemic or cerebral embolism when no cardiac source can be found. Prognosis depends on both the extent of embolization and the clinical condition of the patient before and during treatment.

Adult↗
PubMed1997

Doxycycline reduces early neurologic impairment after cerebral arterial air embolism in the rabbit.

BACKGROUND: Previous studies indicate leukocytes play a role in the pathogenesis of cerebral arterial air embolism. Because doxycycline inhibits numerous leukocyte activities, the authors hypothesized doxycycline would decrease neurologic impairment after cerebral arterial air embolism. METHODS: New Zealand White rabbits anesthetized with methohexital received either intravenous saline (n = 7) or 10 mg/kg doxycycline (n = 7) 1 h before administration of 100 microl/kg of air into the internal carotid artery. Somatosensory-evoked potentials (SSEPs) were recorded at 30-min intervals for the next 2 h. After the final recording, the anesthetic was discontinued, and animals recovered. Animals were neurologically evaluated 4 h after air embolism on a scale of 0 (normal) to 99 (coma) points. RESULTS: At 4 h, doxycycline animals had lesser neurologic impairment (46 +/- 23; median, 41) than animals that received saline (77 +/- 20; median, 81); P = 0.007. SSEP amplitude was greater in the doxycycline group at 60, 90, and 120 min after air embolism; P = 0.001, 0.006, 0.026, respectively. SSEP amplitudes at 30, 60, 90, and 120 min inversely correlated with 4 h neurologic impairment; tau = -0.43, -0.75, -0.85, -0.79, respectively. CONCLUSIONS: Doxycycline decreased electrophysiologic and neurologic abnormalities after cerebral air embolism. Because groups could be distinguished electrophysiologically as soon as 1 h after air embolism and because SSEP amplitude inversely correlated with neurologic impairment, doxycycline appears to inhibit a key early (approximately 1 h) process in the pathophysiology of cerebral air embolism.

Animals↗
PubMedDate not supplied

Atrial septal aneurysm: association with cerebrovascular and peripheral embolic events.

Patient records in 36 consecutively identified patients with typical echocardiographic findings of atrial septal aneurysm were reviewed. Ten of the 36 (28%) had cerebrovascular events. Of these 10, 5 had completed strokes of definite embolic origin on the basis of clinical, angiographic, and computed tomographic findings; 2 had transient ischemic attacks of probable embolic origin. One of the 36 patients had a definite peripheral vascular embolus. Thus, 6 of 36 consecutively identified patients with atrial septal aneurysm (17%) had definite embolic events and 8 of 36 (22%) had definite or possible embolic events. The cause of the association between atrial septal aneurysm and emboli is unknown. While aneurysm-associated thrombus has been suggested, the high proportion (90%) of patients with interatrial shunting demonstrated by contrast echocardiography in this study suggests paradoxical embolization as a potential cause. Whatever its mechanism, the high prevalence of embolic events in this series strongly supports the premise that atrial septal aneurysm is a cardiac abnormality with embolic potential.

Adult↗
PubMed1992

Effect of lidocaine on somatosensory evoked response and cerebral blood flow after canine cerebral air embolism.

BACKGROUND AND PURPOSE: Victims of air embolism often recover rapidly on hyperbaric treatment then deteriorate again, even if hyperbaric treatment is continued. In previous animal experiments, lidocaine has been shown to improve recovery of somatosensory evoked response amplitude after air embolism. However, animals in these experiments rarely deteriorated. We have shown that the induction of air embolism and transient hypertension in canines produces deterioration despite hyperbaric treatment, and we decided to test the effect of lidocaine on somatosensory evoked potential recovery and cerebral blood flow in this model. METHODS: Dogs were treated with repeated doses of lidocaine or equivalent volumes of saline during hyperbaric therapy after internal carotid air embolism and transient hypertension. The investigators were unaware of treatment group assignment during the experiments. The amplitude of the median nerve somatosensory evoked potential and cerebral blood flow measured with carbon-14-labeled iodoantipyrine autoradiography were used to assess effect of therapy. RESULTS: Lidocaine-treated dogs recovered 60 +/- 10% (mean +/- 95% confidence limits) of the baseline somatosensory evoked potential amplitude 220 minutes after air embolism; saline-treated dogs recovered 32 +/- 10% (a significant difference at p less than 0.01). Lidocaine-treated dogs also had higher cerebral blood flow values than saline-treated dogs 220 minutes after air embolism. CONCLUSIONS: Lidocaine ameliorated the delayed deterioration of evoked potential associated with air embolism and hypertension in this canine model. The improved cerebral blood flow may be a mechanism of action of lidocaine or an associated effect of improved neuronal survival.

Animals↗
PubMed1994

Paradoxical embolism as a cause of ischemic stroke of uncertain etiology. A transcranial Doppler sonographic study.

BACKGROUND AND PURPOSE: This study was designed to test the hypothesis that paradoxical embolization would be a cause of embolic strokes and transient ischemic attacks in patients with stroke of uncertain etiology in all age groups. METHODS: Thirty patients who had stroke of uncertain etiology were studied. They were divided into the following three groups: 13 patients with sudden onset (group A), 11 patients with subacute onset (group B), and 6 asymptomatic stroke patients (group C). Eleven patients with stroke of obvious etiology (group D) and 11 normal healthy volunteers (group E) were also studied as controls. In all patients transcranial Doppler sonography and contrast echocardiography were recorded simultaneously after intravenous injection of the contrast medium. Findings of positive patient foramen ovale in contrast echocardiography or "chirp" sounds in transcranial Doppler sonography were defined as positive for paradoxical contrast embolization. Radioisotope phlebography of the lower extremities and pulmonary scintigraphy, using technetium-99 macroaggregated albumin, were performed in all 17 patients who had positive findings of paradoxical contrast embolization and in 12 patients whose findings were negative. RESULTS: Positive findings of paradoxical contrast embolization were found in 17 subjects by transcranial Doppler sonography but in only 8 on contrast echocardiography. These positive findings were detected more frequently in group A (77%) than in groups B, D, and E (9%, 18%, and 9%, respectively) (P < .05). In group C, 4 of 6 patients (67%) had positive findings. There were positive findings on both phlebography and pulmonary scintigraphy only in 6 group A patients, with positive findings of paradoxical contrast embolization. CONCLUSIONS: Transcranial Doppler sonography is a sensitive detector of right-to-left shunts. Paradoxical cerebral embolization might be frequent in patients with stroke of unknown etiology, especially when the stroke is of sudden onset.

Adult↗
PubMed1986

High risk of systemic embolism in hypertrophic cardiomyopathy.

Six of 66 patients with hypertrophic cardiomyopathy had an embolic event during an average observation period of 3.73 years. Five of these had probable cerebral embolism, while 1 patient had a femoral artery embolism. The calculated incidence of systemic embolism was 2.4% per patient year. All embolic events occurred in the patients with atrial fibrillation. In comparison to patients without systemic embolism with or without atrial fibrillation, the cardiothoracic ratio was greater, the cardiac index was lower and the left atrial dimension tended to be greater in those patients with systemic embolism.

Adolescent↗
PubMed2002

Prophylaxis against fat and bone-marrow embolism during total hip arthroplasty reduces the incidence of postoperative deep-vein thrombosis: a controlled, randomized clinical trial.

BACKGROUND: Clinical and experimental studies have suggested that the maximum risk of thrombogenesis occurs during, rather than after, total hip arthroplasty. With use of conventional cementing techniques, insertion of a femoral component results in marrow embolization of tissue thromboplastin into the veins of the proximal part of the femur, leading to activation of the clotting cascade and thrombogenesis. We hypothesized that an operative technique designed for the prevention of fat and bone-marrow embolism can also reduce the incidence of postoperative deep-vein thrombosis and pulmonary embolism. METHODS: A total of 130 consecutive patients with osteoarthritis who were to have a primary total hip arthroplasty were randomly assigned to one of two groups. One group consisted of sixty-five patients (sixty-five hips) who had the femoral component inserted with our standard cementing technique without use of a bone vacuum, and the other group included sixty-five patients (sixty-five hips) who had the femoral component cemented with use of a bone-vacuum technique. In the hips managed with the bone vacuum, suction (-800 mbar) was applied to a drainage cannula placed along the linea aspera of the femur in order to prevent an increase in intramedullary pressure during the insertion of the stem. We measured the incidence of intraoperative fat and bone-marrow embolism with use of echocardiography and a transesophageal probe and the incidence of deep-vein thrombosis with use of serial duplex ultrasonography on the day before the operation and on postoperative days 4, 14, and 45. All patients were managed with prolonged pharmacological prophylaxis (low-molecular-weight heparin) against deep-vein thrombosis. RESULTS: The control group had significantly more severe and prolonged echocardiographic embolic events than did the group managed with the bone-vacuum technique (p < 0.05). A cascade of fine echogenic particles or embolic masses with a diameter of < or =5 mm was observed during the insertion of the stem in fifty-nine hips (91%) in which our standard cementing technique was used and in ten hips (15%) in which the bone-vacuum cementing technique was used. Deep-vein thrombosis was detected on postoperative day 4 in twelve patients (18%) in the control group and in two patients (3%) in the group managed with the bone-vacuum technique; the difference was significant (p < 0.05). CONCLUSIONS: Intraoperative prophylaxis against fat and bone-marrow embolism during total hip arthroplasty with cement can reduce the incidence of postoperative deep-vein thrombosis. We now use the bone-vacuum technique routinely in all total hip arthroplasties performed with cement.

Arthroplasty, Replacement, Hip↗
PubMed2002

Air trapping on CT of patients with pulmonary embolism.

OBJECTIVE: We evaluated the relationship of air trapping to mosaic perfusion in patients with pulmonary embolism. SUBJECTS AND METHODS: Forty-one consecutive patients with suspected pulmonary embolism underwent expiratory CT followed by helical CT angiography. After excluding 12 patients who had airway disease or were smokers, we divided the patients into two groups: those with (n = 15) and without (n = 14) pulmonary embolism. For each patient, six expiratory images were evaluated for the presence of air trapping, and the corresponding six images from CT angiography were evaluated for the presence of mosaic perfusion. Clot locations were assessed on CT angiography and were correlated with the presence of air trapping and mosaic perfusion. RESULTS: In patients with pulmonary embolism, mosaic perfusion was identified in 32 areas (seven patients, 46.7%), and air trapping was identified 68 areas (nine patients, 60%). Of the 32 areas of mosaic perfusion, 23 areas (71.9%) showed air trapping on expiratory CT scans. Of the 68 areas with air trapping on expiratory scans, 23 areas (33.8%) showed mosaic perfusion on inspiratory scans, and 44 areas (64.7%) had clots in the arteries leading to them. Clots were more frequently identified in areas of lower attenuation on inspiratory CT scans and air trapping (21/23) than in those of normal attenuation on inspiratory CT scans and air trapping (23/45) (p < 0.005). Only one patient without pulmonary embolism had air trapping (p < 0.005). CONCLUSION: Air trapping is common in pulmonary embolism and may be the cause of mosaic perfusion. Air trapping can be seen distal to vessels not showing pulmonary embolism.

Adolescent↗
PubMed2000

The utility of transesophageal echocardiography in determining the source of arterial embolization.

Arterial embolism is frequently of a cardiac source. Arterial-arterial and paradoxical embolization also occurs. Failure to identify the origin may subject the patient to an important series of events. Herein we describe seven cases in which transesophageal echocardiography (TEE) was uniquely valuable in identifying the source or mechanism and in which conventional echocardiography and aortography were nondiagnostic. We conducted a chart review of patients with arterial emboli definitively diagnosed after undergoing TEE. Seven patients (mean age 68 years) were included in the study. Peripheral embolization occurred in four patients, visceral embolization occurred in one, and two experienced cerebrovascular events. Five patients had transthoracic echocardiography and six had aortography; none of these identified the source of embolization. All were diagnosed by TEE. Mobile aortic thrombus was the primary source in three patients, paradoxical embolization occurred in two, and two others had a combination of findings. Two patients received operative management with one mortality, and five received nonoperative management. The source of arterial emboli remains obscure in some patients. TEE can be valuable in identifying sources or mechanisms of embolization when angiography and conventional echocardiography are negative.

Aged↗
PubMedDate not supplied

[Arterial embolism of venous origin: a clinical entity to keep always in mind].

In patients with unexplained arterial embolism or unexplained cerebral vascular accidents, a diagnosis of paradoxical embolism should be taken into consideration. It consists in the passage of an embolus, originating in the venous system or the right side of the heart, via an abnormal right to left channel, into the systemic circulation. In the majority of cases the abnormal communication is a patent foramen ovale; its incidence varies from 6% to 29% in unselected autopsies. The diagnosis of paradoxical embolism requires the presence of four Johnson's criteria. Nowadays the diagnostic procedures have been simplified by introducing non-invasive techniques based on ultrasound evaluation. The treatment of paradoxical embolism must be individualized and consists above all in the use of anticoagulants. Here we report a case of right leg paradoxical embolism in a young woman who had been operated on three months earlier for breast cancer. After ilio-femoro-popliteal thromboembolectomy, Doppler of the lower limb veins was performed. The presence of iliac venous thrombosis led to a suspicion of paradoxical embolism, which was then confirmed by the demonstration of a patent foramen ovale. The diagnosis of paradoxical embolism is important because the condition is associated with significant morbidity and mortality rates.

Adult↗
PubMed2005

[Paradoxical brain embolism with a floating deep venous thrombus detected by sonography of lower extremities].

A 68-year-old woman was admitted to our hospital due to brain embolism in the right middle cerebral artery. Patent foramen ovale was detected by transesophageal echocardiogram. The sonogram of the legs revealed a floating thrombus originating from the left posterior tibial vein and extended to the superficial femoral vein. Both right middle lobe and left upper lobe were defected in perfusion scans of lung. She was treated with administration of warfarin potassium and caval filters placed in the inferior vena cava and the azygos vein. Thereafter, she had never experienced brain embolism or pulmonary embolism. A floating deep venous thrombus, which is a high risk of pulmonary embolism, could be observed in patients with paradoxical brain embolism. It was suggested that sonography of veins in the legs is essential for detecting embolic sources of brain infarction, as well as evaluating the risk of pulmonary embolism.

Aged↗
PubMed1979

[Rare etiology of hemiplegia with young adult: paradoxical embolism (author's transl)].

Paradoxical embolism is due to the passage of an embolic material from the deep veins of the lower extremities or pelvis, into the systemic circulation through an abnormal intracardiac communication. Only the angiographic and hemodynamic diagnosis practised on two young patients with a cerebral embolism, can explain the mechanism. The diagnosis is based on the arterial embolism, the venous thrombosis with or without pulmonary embolism, the abnormal communication favoring right-to-left shunting. The rising of right atrial pressures permits this shunting. This high pressure can result from a pulmonary embolism, a high blood pressue due to an effort, or an embolism that might coil up over the tricuspid valve.

Adult↗
PubMed1995

[Significance of pulmonary fat embolism in intra- and early postoperative fatal cases following femoral fractures of the hip region].

Between 1978 and 1994, 130 deaths after hip fractures were investigated at the Institute of Forensic Medicine of the Free University of Berlin. In this period more than 3500 such cases occurred in Berlin. Eight persons were found dead at home, 17 had conservative treatment or died before the planned operation, and 105 had an operation. Hip replacement was carried out in 49, nailing in 17, and other kinds of osteosynthesis (especially using screws) were used in 39 cases. In the surgically treated group, death occurred during the operation in 6 cases (all hip replacements), on the day of operation or the first postoperative day in 7 cases, and within the first week in 21 cases. In the conservative group 10 cases died during the first week after trauma. The main, clearly detectable causes of death were pneumonia (30) and thromboembolism of the lungs (22). Fat embolism was responsible for death in at least 6 cases (3 intra- and 3 postoperative); in 2 additional intraoperative and 7 early postoperative deaths, a potentially lethal fat or bone marrow embolism occurred together with other deadly factors. A fat embolism was present in 9 cases within the first week, diminishing with survival time. Hip replacement was clearly dominant for the genesis of pulmonary fat embolism: in none of the early post-endoprosthetic deaths was there little or no fat embolism in contrast to the other types of operation. Bone marrow embolization can induce the formation of multiple small, red intravenous thrombi-possibly a factor explaining the lethal outcome in only a few cases with intraoperative fat embolism. This form of "thromboembolism" must be differentiated from typical lung thromboembolism, originating from a preceding venous thrombosis.

Aged↗
PubMed2001

[Non-thrombotic pulmonary embolisms].

In the absence of intracardiac or intrapulmonary shunts, the pulmonary microvasculature traps all embolized particles greater than 10 microns. In the vast majority of cases these emboli are venous thrombi which lodge in larger pulmonary arteries, resulting in obstructive phenomena rather than primarily being injurious to lung parenchyma. This review deals exclusively with nonthrombotic pulmonary embolism which involves substances that lodge predominantly in the pulmonary microvessels and cause a true endothelial and parenchymal injury, as well as obstructive phenomena. The article focuses on fat embolism, amniotic fluid embolism, gas embolism, septic emboli, and tumour pulmonary embolism.

Embolism, Air↗
PubMed1998

Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection.

BACKGROUND: The outpatient treatment of patients with deep vein thrombosis and pulmonary embolism using low-molecular-weight heparin has the potential to reduce health care costs, but it is unclear if most patients with deep vein thrombosis and pulmonary embolism can be treated as outpatients. In the published studies, more than 50% of patients were excluded from outpatient treatment for reasons such as comorbid conditions, short life expectancy, concomitant pulmonary embolism, and previous deep vein thrombosis, and many patients were not treated entirely at home. We sought to determine if expanding patient eligibility for the outpatient treatment of deep vein thrombosis and pulmonary embolism affects the safety and effectiveness of the treatment, and to determine if patient self-injection compared with injections administered by a homecare nurse affected these outcomes. PATIENTS AND METHODS: We treated as outpatients all patients with deep vein thrombosis and pulmonary embolism, except for those with massive pulmonary embolism, high risk for major bleeding or an active bleed, phlegmasia, and patients hospitalized for reasons that prevented discharge. We compared 2 models of outpatient care to determine feasibility, safety, and efficacy. Both models involved nurse managers who provided daily patient contact and ongoing treatment; however, in one model the patients were taught to inject themselves and in the other model homecare nurses administered the injections. We expanded the population of patients eligible for outpatient treatment by including many patients not treated at home in previous studies. Most patients in our study were treated with dalteparin sodium, 200 U/kg every 24 hours, for a minimum of 5 days. Therapy with warfarin sodium was started on the day of diagnosis or the following day. Patients were followed up for 3 months to determine rates of recurrent venous thromboembolism, bleeding, and death. RESULTS: In this study, 194 (83%) of 233 consecutive patients were deemed eligible and treated as outpatients. Of the 39 patients who did not receive home therapy, 20 had concomitant medical problems responsible for their admission or were already inpatients, 6 had massive pulmonary embolism, 6 refused to pay for the dalteparin therapy, 4 had active bleeding, and 3 had phlegmasia cerulea dolens, which required treatment with intravenous narcotics for pain control. More than 184 (95%) of the 194 patients were treated entirely at home. There was no significant difference (P>.99) in the rate of recurrent venous thromboembolic events between the patients who were injected by homecare nurses (3/95 [3.2%]) and those who injected themselves (4/99 [4.0%]). Combining the 2 models, the overall recurrent event rate was 3.6% (95% confidence interval, 1.5%-7.4%). Similarly, there were no significant differences in rates of major hemorrhage (2/95 vs 2/99; P>.99), minor hemorrhage (8/95 vs 2/99; P = .06), and death (6/95 vs 8/99; P = .63). The overall rate of major hemorrhage was 2.0% (95% confidence interval, 0.6%-5.2%). CONCLUSIONS: We demonstrate that more than 80% of patients at our tertiary care hospital could be treated at home using 1 of the 2 models of care we describe. Our results demonstrate that patients can safely and effectively perform home self-injection under the supervision of a hospital-based nurse. Injections at home by a homecare nurse are similarly effective. Our overall rates of recurrent venous thromboembolism, bleeding, and death are at least as favorable as those previously reported despite using 1 dose per day of dalteparin for most patients.

Adult↗
PubMed1998

Impending paradoxical embolism.

The advent of echocardiography has led to the more frequent discovery of impending paradoxical embolism. Paradoxical embolism should be considered whenever there is an arterial embolism from an unidentified source in the presence of a concomitant venous thromboembolic phenomenon. Patients with paradoxical embolism present with neurological abnormalities or features suggesting arterial embolism. Annually, paradoxical embolism may account for up to 47,000 strokes in the United States, and a patent foramen ovale has been reported in up to 35% of the normal population. Events that give rise to pulmonary hypertension may result in a right-to-left shunt through a patent foramen ovale allowing a venous thromboembolism access to the arterial circulation. Herein we report a case of impending paradoxical embolism and review the pertinent literature.

Diagnosis, Differential↗
PubMed1996

Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein.

OBJECTIVE: To describe indications and surgical techniques for embolization of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a cannulated superior ophthalmic vein based on our clinical experience. DESIGN: Retrospective clinical review. SETTING: University tertiary referral hospital and eye institute. PATIENTS: Over a 3-year period, 10 consecutive patients with CDF and progressive orbital congestion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatment of fistulas on the basis of progressive glaucoma refractory to medical management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combination of these findings. INTERVENTION: Nine of the 10 patients underwent anterior orbitotomy via a lid-crease or sub-brow incision with cannulation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful transarterial embolization. One patient underwent a primary transvenous embolization. MAIN OUTCOME MEASURES: Successful closure of the fistula on angiography, return of baseline visual acuity, normalization of postoperative intraocular pressure, and cosmetically acceptable cutaneous scar. RESULTS: All 10 patients had prompt resolution of symptoms and halt of progressive visual loss following occlusion of the fistulas. Two patients had no flow in the anterior superior ophthalmic vein on angiography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization was successfully performed. In 2 additional patients with nondilated superior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small vein. CONCLUSIONS: When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for CDF and perhaps should be employed as primary therapy in cases with progressive orbital congestive symptoms. If the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.

Adult↗