Carotid Cavernous Fistulae

Endovascular technology has advanced to the point that it has monopolized the treatment of CCF. The creation of microcatheters and a variety of embolic agents has established this modality as the treatment of choice for CCFs. The goal of therapy is to obliterate the fistula and preserve the parent artery. In rare cases, the cavernous carotid artery may have to be sacrificed to preserve visual function. CCFs are classified into two types: direct and indirect, with indirect fistula further classified on the basis of arterial supply (45). The direct, or type A, fistula is generally posttraumatic in nature and involves a direct connection between the internal carotid artery (ICA) and cavernous sinus. These may also result from rupture of an intracavernous aneurysm. The indirect type is an arte-riovenous fistula located within the dura surrounding the cavernous sinus and is characterized by multiple arteries from the dura supplying the fistule. Type B CCFs are supplied by small branches of the cavernous segment of the ICA and is exceedingly rare. Type C CCFs are supplied by dural branches of the external carotid artery. Type D CCFs are supplied by branches from both the internal and external carotid arteries (45).

The transarterial approach is preferred for most direct CCFs. Alternatively, the transvenous approach can be used when the transarterial route is impossible. The cavernous sinus can be accessed either through the inferior petrosal sinus or the superior ophthalmic vein (46,47). In complex cases, a combination of the two may be necessary. Surgical exposure of the sinus may be necessary when the endovascular routes are impermeable or embolic materials result in venous outflow obstruction leading to clinical deterioration (48). More recently, we have utilized an approach to selected cases through transorbital puncture of the cavernous sinus through the superior orbital fissure (49). The transvenous route carries the lowest risk but also the lowest success rate owing to difficulty in negotiating the multicompartmental sinuses (50).

The treatment of indirect CCFs is through the tranvenous route. The multiple arterial feeders supplying these lesions make transarterial embolization less successful. Continued advances in catheter technology and embolic agents may improve the obliteration rates, with minimal complications.

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