We have read with great interest the article by Henderson and Miller regarding the endovascular management of dural carotid-cavernous fistulas with a transvenous approach via the superior ophthalmic vein [1]. An anterior orbitotomy allows the superior ophthalmic vein to be identified, and a venous catheter inserted and advanced into the cavernous sinus with a success rate for transvenous procedures reported at around 80% [1]. Carotid-cavernous fistulas are associated with a dilatation of the superior ophthalmic vein, however, challenges to their identification and cannulation arise in cases of small, fragile, anomalous or thrombosed veins [2].

Based on our experience, we would like to report the use of an intraoperative Valsalva manoeuvre to assist cannulation of the superior ophthalmic vein. A 60-year-old gentleman underwent endovascular repair with a transvenous approach via the superior ophthalmic vein of a dural carotid-cavernous fistula. An anterior orbitotomy approach identified the superior ophthalmic vein, although cannulation proved challenging as the vein was small and fragile. An intraoperative anaesthetist controlled Valsalva manoeuvre was performed, which produced a prominent dilatation of the vein and enabled a successful cannulation. This technique may also be used to identify a small or anomalous superior ophthalmic vein.

Head and neck surgery may be associated with life-threatening post-operative bleeding. Subsequently, numerous publications discuss intraoperative Valsalva manoeuvre and Trendelenburg positioning to assist identification of bleeding vessels [3, 4]. To our knowledge, this is the first report of intraoperative Valsalva manoeuvre used to assist ophthalmic vein cannulation, and hope this may be considered in similar challenging cases.