• Haydn Hoffman, Ashok KumarApekshaADepartment of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA., Jacob S Wood, Tatiana Mikhailova, Jae Hyun Yoo, Melia B Wakeman, Hesham E Masoud, and Grahame C Gould.
• Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA. Electronic address: hoffmanh@upstate.edu.
• World Neurosurg. 2023 Feb 1; 170: e242e255e242-e255.

BackgroundDirect carotid cavernous fistulas (dCCF) involve pathologic shunting from the internal carotid artery into the cavernous sinus. We systematically reviewed the methods and outcomes of endovascular therapy for dCCF.MethodsPubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for patients undergoing embolization of dCCF. Outcomes included rates of occlusion, complications, symptom improvement, and recurrence. Pooled rates for each outcome were obtained with random effects models. The influence of embolization method on outcomes was assessed with meta-regressions.ResultsThere were 16 studies comprising 270 patients. The mean age was 39.6 years, there were 36.3% females, and the mean follow-up was 19.7 months. Coils were the most common method of embolization (69.3%), followed by Onyx (31.1%), covered stent (22.2%), N-butyl cyanoacrylate (6.7%), and flow diversion (4.8%). The pooled overall occlusion rate was 92.1% (95% confidence interval [CI], 86.3-95.6; I2 = 29.2%). The pooled complication rate was 10.9% (95% CI, 7.3-16; I2 = 0%). Use of coils were associated with a slightly lower odds of overall complications (odds ratio, 0.98; 95% CI, 0.97-0.99) and cranial nerve palsy (odds ratio, 0.98; 95% CI, 0.97-0.99). The pooled fistula recurrence rate was 8.3% (95% CI, 4.3-15.4; I2 = 30.9%).ConclusionsEndovascular therapy for dCCF is associated with high occlusion and low complication rates. Recurrence is not uncommon, highlighting the need for close follow-up.Copyright © 2022 Elsevier Inc. All rights reserved.

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