Multimodal Management of Carotid-Cavernous Fistulas

Abstract Background Techniques for endovascular management of carotid-cavernous fistulas (CCF) have evolved over the years. Current strategies include transarterial or transvenous approaches, and direct puncture or exposure of the cavernous sinus (CS). Rarely, complex fistulas may require multiple approaches or procedures. We describe our experience managing these lesions, reporting on outcomes and technical nuances. Methods A retrospective review of our institutional records was conducted to identify consecutive cases of CCF treated at Jackson Memorial Hospital between July 2005 and July 2016. Pertinent technical details and outcomes were recorded. Results Fifty-one procedures were performed in 44 patients. Thirteen fistulas were direct and 31 were indirect: 30% (n=13) Type A, 7% (n=3) Type B, 11% (n=5) Type C, 52% (n=23) Type D. A transarterial approach was selected in 39% of cases (n=20), resulting in a long-term successful embolization rate of 60% (n=12). Transvenous methods via the inferior petrosal sinus or superior ophthalmic vein (SOV) were utilized in 49% of cases (n=25), resulting in a long-term obliteration rate of 88% (n=22). Multimodal management was required in 5 patients including one in whom a craniotomy was performed to facilitate coil embolization of the CS under direct vision. A 7% complication rate (n=3) was observed resulting in significant morbidity in one patient. Conclusions CCFs are complex vascular lesions that require facility with various endovascular and surgical approaches. High flow, direct-type fistulas may harbor a significant risk of recurrence after transarterial embolization. Partial or unsuccessful embolization may necessitate an open surgical approach to the SOV or CS.