Introduction: The endovascular treatment of carotid cavernous fistulas(CCFs) has evolved to include both transarterial and transvenous embolization using detachable balloons, coils, and liquid embolic agents. The present series comprises our 16-year institutional experience in the endovascular treatment of CCF.

Methods: We reviewed our prospectively-maintained database for patients evaluated for endovascular treatment for CCF between 12/1995-12/2011. Relevant clinical and demographic data were extracted for 95 patients from medical records, operative notes, and radiographic reports.

Results: Of 40 patients with direct CCF, 37 were successfully treated using endovascular techniques(93%), with an overall 10% morbidity and 2.5% mortality. From 12/1995 to 3/2004, detachable balloons were used in 18/22 direct CCF cases. Occlusion of the internal carotid artery(ICA) occurred in 50% of these cases. Trans-arterial coil embolization, both with and without adjunctive balloon remodeling/stent assistance, was undertaken in 14/18 direct CCF patients treated after 3/2004. The ICA was preserved in 10 patients undergoing transarterial coil embolization(71%), whereas 4(29%) required carotid occlusion. Of the 22 patients treated in the detachable balloon era, 4(18%) exhibited residual fistula. By comparison, of the 15 patients successfully-treated in the modern era, 1(7%) exhibited residual. Of the 55 patients with indirect CCF, 42 were successfully treated using endovascular techniques(76%), with transvenous embolization as first-line treatment. The overall morbidity was 7.2% and mortality was 0%. Venous approaches included transfemoral access via the inferior petrosal sinus(n=19) or facial vein(n=9), and direct cutdown(n=7) or percutaneous(n=3) access to the ophthalmic veins. Of the 42 patients successfully-treated, 7(17%) exhibited residual fistula.

Conclusions: Advances in endovascular technology have inspired an evolution in the treatment of CCF. For direct CCF, trans-arterial coil embolization with adjunctive stent/balloon assistance has evolved as first-line treatment. For indirect CCF, improvements in venous access have facilitated treatment of lesions with restricted venous outflow.

Patient Care: An analysis of the the evolution of endovascular techniques in the treatment of CCF may lead to further refinements of techniques and improved outcomes.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Understand the anatomy and pathogenesis of both direct and indirect CCFs, 2) Describe the current options endovascular treatment of each of these classes of fistula, and 3) Appreciate how advances in endovascular materials and techniques have led to an evolution in treatment of CCF.

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