Central Retinal Artery–Oriented Embolization of Periorbital Arteriovenous Malformations: Distal Ophthalmic Artery Coil Protection Enabling Aggressive Nidus Treatment

BACKGROUND AND PURPOSE: Periorbital AVMs are frequently supplied by the ophthalmic artery. Its branch, the central retinal artery, has no effective collateral supply; inadvertent embolization may therefore cause irreversible blindness. Because vision loss has been reported after both transophthalmic and external carotid approaches, these lesions are often observed or incompletely embolized. We evaluated the feasibility, safety, and outcomes of a strategy mechanically protecting the retinal circulation with coils placed distal to the central retinal artery, enabling aggressive nidus embolization. MATERIALS AND METHODS: We retrospectively reviewed 10 consecutive patients with periorbital, palpebral, or adjacent mid-facial AVMs treated at one institution between October 2013 and November 2023. Lesions outside the periorbital region were included only with angiographic ophthalmic artery contribution. When the ophthalmic artery supplied the lesion, it was selectively catheterized and, when feasible, coils were deployed beyond the central retinal artery; the nidus was then embolized with 25% n-BCA through external carotid feeders or by direct puncture, with limited reflux intentionally accepted. Ophthalmic artery catheterization, distal coil protection, n-BCA delivery, immediate obliteration, adverse events, and clinical outcome were assessed. RESULTS: Ten patients (7 women, 3 men; median age, 29.5 years; range, 15-51) were treated. The ophthalmic artery contributed in 9 of 10 patients; the dominant feeder was the external carotid artery in 8, mixed in 1, and ophthalmic in 1. Selective ophthalmic artery catheterization succeeded in all 12 involved arteries, and distal coil protection was achieved in 11 of 12 arteries (in 8 of 9 patients with ophthalmic artery involvement). n-BCA was successfully delivered to the intended nidus in all 10 patients. Immediate obliteration was complete in 7 patients, near-complete in 1, and partial in 2. No vision-threatening complication occurred; 1 required grafting for skin necrosis. Over a median follow-up of 8.5 years (2.5-12 years), no patient showed clinical progression or recurrence. CONCLUSIONS: Distal ophthalmic artery coil protection provides a fixed anatomic barrier that is independent of the injection route, facilitating aggressive nidus embolization of periorbital AVMs without observed vision-threatening complications. Ophthalmic artery involvement should not preclude curative embolization when the retinal circulation can be mechanically protected.