Introduction: Techniques for endovascular management of carotid-cavernous fistulas (CCF) have evolved over the years after withdrawal of detachable balloons from the market. Current strategies include the trans-arterial or trans-venous approach, and direct puncture or exposure of the cavernous sinus (CS). Rarely, a complex fistula may require multiple approaches or procedures. Here we describe our experience managing these complex lesions and report 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, Miami FL, between 2005 and 2016. Technical details including approach and choice of embolic material were recorded. Outcomes were based on follow-up angiographic and clinical findings.
Results: Fifty-nine procedures were performed in 44 patients. Angiographic classification of the fistulas was as follows: 32% (n=14) Type A, 7% (n=3) Type B, 11% (n=5) Type C, 50% (n=22) Type D. A trans-arterial approach was selected in 42% (n=25) of cases, resulting in a long-term successful embolization rate of 40% (n=10). Trans-venous methods included access to the CS via the inferior petrosal sinus, superior ophthalmic vein (SOV) via the facial vein, and direct access to the SOV via surgical exposure in the orbit. The trans-venous approach resulted in a long-term obliteration rate of 83%. Multimodal management was required in 10 cases including two instances where a frontotemporal craniotomy was performed to allow placement of a vascular sheath into the CS under direct vision, thus facilitating coil embolization. A 5% complication rate (n=3) was observed resulting in significant morbidity in a single patient.
Conclusions: CCFs are complex vascular lesions of the skull base which require facility with various endovascular and surgical approaches. High flow, direct-type fistulas may harbor a significant risk of recurrence after trans-arterial embolization. Partial or unsuccessful embolization may necessitate an open surgical approach to the SOV or CS.
Patient Care: Our research provides insight into the choice of treatment for carotid-cavernous fistulas and identifies predictors of a successful outcome.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Identify the various approaches and techniques for treating carotid-cavernous fistulas, 2) Discuss, in small groups, the pros and cons of common techniques, 3) Identify an effective strategy for treating carotid-cavernous fistulas.