2026 Proffered Presentations
S023: TRANSORBITAL PUNCTURE APPROACHES FOR CAVERNOUS SINUS DURAL ARTERIOVENOUS FISTULA EMBOLIZATION: A SINGLE-ARM META-ANALYSIS OF TECHNICAL SUCCESS AND SAFETY OUTCOMES
Khushal Gupta, MBBS1; Michael Karsy, MD, PhD, MSc, FAANS, FCNS2; 1Bharat Ratna Late Shri Atal Bihari Vajpayee Memorial Medical College; 2University of Michigan Health
Introduction: Cavernous sinus dural arteriovenous fistulas (CS-dAVFs) are challenging vascular lesions, particularly when traditional transvenous access routes such as the inferior petrosal sinus are unavailable. Transorbital puncture, via the superior ophthalmic vein, inferior ophthalmic vein, or superior orbital fissure, has emerged as an alternative strategy for embolization. While promising results have been reported in small series, a consolidated assessment of efficacy and safety has been lacking. We conducted a single-arm meta-analysis to evaluate technical success, symptom resolution, recurrence, and complication rates following transorbital puncture for CS-dAVF embolization.
Methods: This systematic review and meta-analysis was performed in accordance with PRISMA guidelines. PubMed, Embase, Scopus, and Web of Science were searched from inception to July 2025 using predefined terms for “transorbital,” “ophthalmic vein,” and “cavernous sinus fistula.” Studies with ≥5 patients undergoing transorbital puncture for CS-dAVF embolization and with extractable outcome data were eligible. Two independent reviewers screened titles, abstracts, and full texts, with discrepancies resolved by consensus. Data were extracted in duplicate for study design, demographics, fistula characteristics, access route, embolic materials, and outcomes. The primary endpoint was technical success, defined as successful catheterization and embolization of the fistula. Secondary endpoints included symptom resolution, recurrence, any complication, and major complication. Random-effects models (DerSimonian–Laird) were applied to calculate pooled proportions with 95% confidence intervals (CI). Heterogeneity was assessed with the I² statistic and τ², while prediction intervals were generated to reflect the expected range of future study outcomes.
Results: A total of eight studies comprising 157 patients were included. Most cases involved indirect Barrow type B–D fistulas, with embolization performed using coils, Onyx, or a combination. Technical success was consistently high across all reports, with a pooled rate of 100% (95% CI: 98–100%) and no heterogeneity (I² = 0%). Symptom resolution mirrored these findings, as nearly all patients experienced complete or marked clinical improvement. The pooled resolution rate was 100% (95% CI: 97–100%), again with no heterogeneity, underscoring the robust clinical benefit of this approach. Durability of treatment was also excellent. Recurrence after embolization was exceedingly rare, with a pooled rate of 0% (95% CI: 0–2%). Similarly, major complications were virtually absent, with no disabling or fatal events reported (pooled rate: 0% [95% CI: 0–2%]). When all adverse events were considered, however, the pooled incidence of any complication was 28% (95% CI: 10–49%), with substantial heterogeneity (I² = 85%). These complications were almost exclusively transient, including orbital swelling, neuralgia, or minor venous injuries, and resolved without long-term morbidity. Importantly, no study reported procedure-related mortality.
Conclusion: Transorbital puncture represents a highly effective and safe salvage strategy for the treatment of cavernous sinus dAVFs when conventional venous access is not feasible. This approach achieves near-universal technical success and durable symptom resolution, with no risk of major complications and only a modest rate of transient, self-limiting adverse events. These findings strongly support the integration of transorbital access into contemporary treatment algorithms for CS-dAVF management.
