Carotid Cavernous Fistulas

Carotid cavernous fistulas (CCF; also referred to as cavernous sinus arterio-venous malformations (CS-AVF)) represent a pathologic connection between branches of the internal and/or external carotid artery and the cavernous sinus. CCFs can be classified as direct or indirect (dural) depending on clinical characteristics and cause of origin. Standard endovascular approaches for dural CCF treatment include transvenous embolization through the inferior petrosal sinus or the facial vein and transarterial embolization. In some cases, these approaches are not feasible or not successful due to anatomical variations, so alternative techniques are needed. For those patients, transorbital approaches represent a feasible and, in experienced hands, highly effective alternative route for CCF embolization. In this chapter, we describe different variations of transorbital CCF embolization techniques and discuss their advantages and disadvantages. Finally, we give recommendations for patient selection and the choice of surgical approach based on literature data and our own experience.