For direct fistulas, transarterial balloon occlusion is the best option. Detachable balloons can be flow-directed through the fistula with the balloon lodged in the sinus. It is inflated to a larger volume than the fistulous hole, sealing it and preventing prolapse of the balloon back onto the parent vessel. If this fails, transvenous occlusion of the fistula with coils may be attempted. If this fails, occlusion of the ICA may be necessary: this is carried out after test occlusion [28].

With indirect fistulas, if the supply is solely from the ECA, it may be possible to achieve cure with embolization with PVA particles. If there is also ICA supply, the best approach is transve-nous embolization of the cavernous sinus with coils [29]. Fig. 19.4 illustrates successful embolization of a dural fistula fed by branches of both external and internal carotid arteries.

Embolization of Head and Neck Tumors

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