E-025 Transorbital endovascular embolization of carotid-cavernous fistulas: a case series

Introduction/Purpose Carotid-cavernous fistulas (CCFs) are typically managed by embolization, with varied approaches described. Direct transorbital venous access may be utilized if anatomic constraints limit fistulous access via standard venous or arterial access. We present eight cases of successful CCF obliteration through direct transorbital puncture of the cavernous sinus or through indirect cannulation via the superior or inferior ophthalmic veins. Materials and Methods Patient data was gathered through retrospective chart review from August 2017 to December 2019. Demographics, fistula type, treatment method, obliteration status, and complications were recorded. Results Eight patients (M:4, F:4, age 44 ± 15 years) were identified who underwent a transorbital approach for treatment of CCF. Six CCFs were spontaneous, and two were deemed to be traumatic in nature following motor vehicle accidents. One patient had a direct fistula (Barrow type A), while the remainder had indirect fistulas (Barrow types B, C, D). Three patients underwent a direct transorbital embolization; one underwent transarterial embolization followed by transorbital embolization; one underwent transarterial embolization, attempted transvenous embolization, followed by a direct transorbital embolization; one underwent attempted transvenous embolization followed by direct transorbital embolization; and two underwent transarterial embolization, followed by transvenous embolization, followed by direct transorbital embolization. Fistulous occlusion was achieved in all patients following transorbital embolization. Seven patients demonstrated complete resolution of ophthalmic symptoms with normalization of intraocular pressures. One of these patients required an immediate post-operative lateral canthotomy due to transient elevated intraocular pressure from complete occlusion of the inferior orbital vein, though no visual sequelae were noted at follow up and intraocular pressure normalized over the following weeks. One patient who underwent multiple interventions—and ultimately fistula obliteration—progressed to blindness in the affected eye as her treatment course was prolonged. Conclusion Direct percutaneous transorbital puncture is a generally safe and effective means of accessing and treating CCFs. Ophthalmologic cut-down is unnecessary in most cases, and inaccessibility of the superior or inferior orbital veins can be overcome through direct transorbital puncture of the cavernous sinus. Disclosures B. King: None. J. Steinberg: None. A. Wali: None. R. Rennert: None. D. Santiago-Dieppa: None. J. Pannell: None. A. Khalessi: None. S. Olson: None.