{
  "abstract": "Introduction Trans-torcular endovascular approach can be useful for specific venous interventions where access to the contralateral venous system is necessary. This technique can be employed in patients requiring bilateral venous sinus stenting and in situations where there are anatomic advantages with crossing the torcula such as direct access to a fistula pouch for transvenous dural arteriovenous fistula treatment. This study represents the first clinical experience exploring trans-torcular neuroendovascular treatments in light of variations in torcular anatomy, tools associated for success and underlying limitations with this approach.Methods We retrospectively evaluated 44 patients prospectively enrolled at the Hospital of the University of Pennsylvania between September 2022-February 2026. Patients in whom transtorcular intervention was attempted (right-to-left or left-to-right) for venous sinus stenting (VSS) or dAVF embolization were eligible for inclusion. The standard set of guide catheters, intermediate catheters, microcatheters, microwires, stents, and coils were used. Imaging studies captured intraoperatively were reviewed to assess navigation challenges and torcular anatomy. R Studio was used for all analyses performed.Results The cohort commonly possessed a dominant right sided venous drainage system (60%) with most attempted interventions being right-to-left across the torcula (86%). Patients underwent transtorcular intervention mostly due to requiring bilateral stenting (14/29; 48%) or due to failure to select the ipsilateral IJV (4/29; 13.7%). Among the 29 VSS patients, the length of the most distal stent employed was 60 or 80 mm. The guide catheter’s tip was positioned most frequently in the ipsilateral transverse sinus (13/29, 45% for VSS; 6/15, 40% for dAVFs), with the most distal stent/coil deployment site involving the contralateral transverse-sigmoid junction (16/29, 55% for VSS; 10/15, 67% for dAVFs). A standard torcular confluence was observed in 80% of patients with others possessing a fenestrated (n=5) or bifid torcula (n=3). Trans-torcular navigation was successful in all patients with a fenestrated torcula although the stent failed to deploy in one case. Meanwhile, navigation across the torcula was unsuccessful in two cases owing to a bifid torcula (Kobayashi grade IVb). One dAVF embolization procedure had to be abandoned midway owing to nontarget embolization of the distal right vein of Labbe while another required rescue capture of an ipsilaterally herniated coil using the Scepter balloon. The remaining 88% of cases were successful with no complications observed. Average fluoroscopy times were 46 and 111 minutes for VSS and dAVF cases, respectively, with concomitant coiling of emissary veins or diverticula being performed in 23% of patients. No difference in procedural outcomes or complications was observed between patients undergoing VSS as compared to those undergoing dAVF embolization (all p>0.05).Conclusions This study demonstrates success of the transtorcular route in the vast majority of patients undergoing venous neuroendovascular procedures. Our findings suggest that the guide catheter may be optimally positioned in the ipsilateral transverse sinus to enable successful treatment of a contralateral stenosis or dAVF. However, variations in torcular anatomy, such as a bifid torcula may represent significant challenges in transtorcular navigation and must be taken into consideration.Disclosures W. Ahmed: None. O. Gandhi: None. L. Bagley: None. O. Choudhri: None.",
  "authors": [
    {
      "affiliations": [
        "Medical College, Aga Khan University, Karachi, Pakistan"
      ],
      "name": "W Ahmed"
    },
    {
      "affiliations": [
        "Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA"
      ],
      "name": "O Gandhi"
    },
    {
      "affiliations": [
        "Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA"
      ],
      "name": "L Bagley"
    },
    {
      "affiliations": [
        "Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA"
      ],
      "name": "O Choudhri"
    }
  ],
  "title": "E-228 Trans-torcular approach for cerebral venous interventions: a clinical experience in 44 patients",
  "uid": "331d4a18-b952-5852-a36a-728b67b74a59"
}