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.
References: Archondakis E, Pero G, Valvassori L, Boccardi E, Scialfa G. 2007. Angiographic follow-up of traumatic carotid cavernous fistulas treated with endovascular stent graft placement. AJNR Am J Neuroradiol 28(2):342-347.
Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. 1985. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg 62(2):248-256.
Dashti SR, Fiorella D, Spetzler RF, Albuquerque FC, McDougall CG. 2011. Transorbital endovascular embolization of dural carotid-cavernous fistula: access to cavernous sinus through direct puncture: case examples and technical report. Neurosurgery 68(1 Suppl Operative):75-83; discussion 83.
Debrun G, Lacour P, Vinuela F, Fox A, Drake CG, Caron JP. 1981. Treatment of 54 traumatic carotid-cavernous fistulas. J Neurosurg 55(5):678-692.
Gemmete JJ, Ansari SA, Gandhi D. 2009. Endovascular treatment of carotid cavernous fistulas. Neuroimaging Clin N Am 19(2):241-255, Table of Contents.
Gomez F, Escobar W, Gomez AM, Gomez JF, Anaya CA. 2007. Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients. AJNR Am J Neuroradiol 28(9):1762-1768.
Goto K, Hieshima GB, Higashida RT, Halbach VV, Bentson JR, Mehringer CM, Pribram HF. 1986. Treatment of direct carotid cavernous sinus fistulae. Various therapeutic approaches and results in 148 cases. Acta Radiol Suppl 369:576-579.
Higashida RT, Halbach VV, Tsai FY, Norman D, Pribram HF, Mehringer CM, Hieshima GB. 1989. Interventional neurovascular treatment of traumatic carotid and vertebral artery lesions: results in 234 cases. AJR Am J Roentgenol 153(3):577-582.
Kupersmith MJ, Berenstein A, Choi IS, Warren F, Flamm E. 1988. Management of nontraumatic vascular shunts involving the cavernous sinus. Ophthalmology 95(1):121-130.
Lewis AI, Tomsick TA, Tew JM, Jr. 1995. Management of 100 consecutive direct carotid-cavernous fistulas: results of treatment with detachable balloons. Neurosurgery 36(2):239-244; discussion 244-235.
Li J, Lan ZG, Xie XD, You C, He M. 2010. Traumatic carotid-cavernous fistulas treated with covered stents: experience of 12 cases. World Neurosurg 73(5):514-519.
Meyers PM, Halbach VV, Dowd CF, Lempert TE, Malek AM, Phatouros CC, Lefler JE, Higashida RT. 2002. Dural carotid cavernous fistula: definitive endovascular management and long-term follow-up. Am J Ophthalmol 134(1):85-92.
Onizuka M, Mori K, Takahashi N, Kawahara I, Hiu T, Toda K, Baba H, Yonekura M. 2003. Gamma knife surgery for the treatment of spontaneous dural carotid-cavernous fistulas. Neurol Med Chir (Tokyo) 43(10):477-482; discussion 482-473.
Pan HC, Sun MH, Sheehan J, Sheu ML, Chen CC, Lee HT, Chiu WT, Yang DY. 2010. Radiosurgery for dural carotid-cavernous sinus fistulas: Gamma Knife compared with XKnife radiosurgery. J Neurosurg 113 Suppl:9-20.
Preechawat P, Narmkerd P, Jiarakongmun P, Poonyathalang A, Pongpech SM. 2008. Dural carotid cavernous sinus fistula: ocular characteristics, endovascular management and clinical outcome. J Med Assoc Thai 91(6):852-858.
Sergott RC, Grossman RI, Savino PJ, Bosley TM, Schatz NJ. 1987. The syndrome of paradoxical worsening of dural-cavernous sinus arteriovenous malformations. Ophthalmology 94(3):205-212.
Tiewei Q, Ali A, Shaolei G, Feng L, Zhongsong S, Xuesong L, Zhengsong H. 2010. Carotid cavernous fistulas treated by endovascular covered stent grafts with follow-up results. Br J Neurosurg 24(4):435-440.
Tjoumakaris SI, Jabbour PM, Rosenwasser RH. 2009. Neuroendovascular management of carotid cavernous fistulae. Neurosurg Clin N Am 20(4):447-452.
Wang C, Xie X, You C, Zhang C, Cheng M, He M, Sun H, Mao B. 2009. Placement of covered stents for the treatment of direct carotid cavernous fistulas. AJNR Am J Neuroradiol 30(7):1342-1346.
Wang W, Li YD, Li MH, Tan HQ, Gu BX, Wang J, Zhang PL. 2011. Endovascular treatment of post-traumatic direct carotid-cavernous fistulas: A single-center experience. J Clin Neurosci 18(1):24-28.