Five direct carotid-cavernous fistulas (direct CCFs) in four patients were treated by an endovascular technique using detachable coils. The embolizations were performed according to one of two strategies. 1) By embolizing the fistula, that is the compartment of the cavernous sinus adjacent to the fistula orifice, after embolization of the draining veins. 2) By embolizing the fistula only. The former strategy was used to treat first two cases and the latter to treat other three cases. In two of the cases in which only the fistula was embolized, a microcatheter was placed in the draining vein via a transvenous route before-hand, in the event that the embolization resulted in an incomplete closure and the draining veins became inaccessible. In four cases, a complete cure was achieved with preservation of the internal carotid artery and in one case, the internal carotid artery containing the fistula was occluded. The embolization of direct CCFs with detachable coils, which are suitable for both transarterial and transvenous approaches, has several advantages over balloon embolization. We believe this procedure will become an alternative treatment.
Devastating iatrogenic internal carotid artery rupture in endoscopic endonasal surgery rescued by a covered stent
