Salvage transorbital approach for the endovascular treatment of carotid cavernous fistulas

Purpose Carotid cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus (CS) and carotid arteries. In direct CCFs, a transarterial route is often the preferred vascular access; in case of indirect CCFs, the complex anatomy of the feeder vessels and their extra-intracranial anastomosis makes the transarterial embolization challenging and often ineffective. The aim of this study was to review our experience with the transorbital approach to treat patients affected by CCF who have already experienced an endovascular failure procedure, in order to assess this salvage technique feasibility, by analyzing possible risks and complications. Methods We performed a retrospective study of all patients affected by CCFs who underwent transorbital embolization between February 2017 and February 2019 at our institution. Results All patients (3 cases) tolerated both the retrograde embolization and the direct surgical approach with clinical improvement; the closure of the fistula was complete and verified intraoperatively by angiography. Esthetic result was acceptable in all cases with reduction of the proptosis and the intraocular pressure, and increased visual acuity. There were no complications or clinical recurrence. Conclusion Transorbital approach for the endovascular treatment of CCFs is a feasible and safe salvage procedure, which can find indication after other endovascular access failures.