Endovascular treatment of direct carotid cavernous fistulae: A pictorial review

Introduction: Direct carotid-cavernous fistulae (CCFs) are type A fistulae according to Barrow's classification. Endovascular treatment of these lesions is challenging. Methods: The purpose of this review was to evaluate the endovascular treatment of direct CCFs. We also describe the technique, symptomatology and complications associated with the procedure and report on the long-term follow-up in our treated patients. Results: A total of 89 patients with a direct CCF were treated. All patients had baseline brain CT or MR imaging. Treatment comprised transarterial balloon or coil embolizations. The patients were followed up at 1 month and then every 6 months thereafter. Detachable balloons were used in 79 fistulae. In 12 fistulae the balloon could not be negotiated through the fistula and these fistulae were treated with transarterial coil occlusion. Clinical outcomes of the treated patients evaluated at 1 month were: 79 patients (88.8%) cured, 9 (10.1%) significantly improved, 1 (1.1%) remaining static. Conclusion: Endovascular treatment of direct CCFs is safe and effective and results in long-term cure.