• Samir Sur, Simon A Menaker, Carlos Alvarez, Stephanie Chen, Sumedh S Shah, Eric C Peterson, Mohamed Samy Elhammady, and Robert M Starke.
• Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
• World Neurosurg. 2020 Jan 1; 133: e796-e803.

BackgroundTechniques for endovascular management of carotid-cavernous fistulas (CCFs) have evolved over the years. Current strategies include transarterial or transvenous approaches and direct puncture or exposure of the cavernous sinus. Rarely, complex CCFs may require multiple approaches or procedures. We describe our experience managing CCFs, reporting on outcomes and technical nuances.MethodsA retrospective review of institutional records was conducted to identify consecutive cases of CCF treated between July 2005 and July 2016. Pertinent technical details and outcomes were recorded.ResultsIn 44 patients, 51 procedures were performed. There were 13 direct CCFs and 31 indirect CCFs: 13 (30%) type A, 3 (7%) type B, 5 (11%) type C, and 23 (52%) type D. A transarterial approach was selected in 39% of cases (n = 20), resulting in a long-term successful embolization rate of 60% (n = 12). Transvenous methods via the inferior petrosal sinus or superior ophthalmic vein were used in 49% of cases (n = 25), resulting in a long-term obliteration rate of 88% (n = 22). Multimodal management was required in 5 patients, including 1 patient in whom a craniotomy was performed to facilitate coil embolization of the cavernous sinus under direct vision. A 7% complication rate (n = 3) was observed, with significant morbidity in 1 patient.ConclusionsCCFs are complex vascular lesions that require facility with various endovascular and surgical approaches. High-flow, direct-type fistulas may harbor a significant risk of recurrence after transarterial embolization. Partial or unsuccessful embolization may necessitate an open surgical approach to the superior ophthalmic vein or cavernous sinus.Copyright © 2019 Elsevier Inc. All rights reserved.

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