Transcavernous Surgical Approach for the Treatment of Carotid-Cavernous Fistula: 2-Dimensional Operative Video.

Carotid-cavernous fistulas (CCFs) are abnormal connections between arteries and veins of the cavernous sinus.1 We describe a case of a 71-year-old woman presenting with left eye redness, chemosis, and proptosis over 4 months. Computed tomography and cerebral angiogram demonstrated an indirect CCF, with an enlarged venous pouch draining to a dilated left superior ophthalmic vein, without communication to the posterior portion of the cavernous sinus. Transvenous endovascular embolization through inferior petrous sinus and facial veins was attempted. However, it was unsuccessful because of the lack of venous access to the fistula. Subsequently, direct cannulation of the superior ophthalmic vein was also attempted, but again unsuccessful. A transcavernous open surgical approach was performed. The lateral wall of the cavernous sinus was exposed, and a puncture to the fistula point through the anteriomedial triangle was performed, followed by the injection of a flowable hemostatic matrix with thrombin. Informed consent for all procedures was provided. Patient had substantial improvement of the left eye congestion and proptosis immediately after the operation. Postoperative angiogram and 6-month MRA confirmed the exclusion of the CCF. Open surgical treatment of indirect CCF has been classically described before the development of modern endovascular techniques, consisting in trapping the internal carotid artery or exposing and packing its cavernous branches, through the anterolateral triangle.2 Nowadays, endovascular technique is considered the preferred method for indirect CCF.1 When standard and less invasive techniques fail, transcavernous surgical approach as we present in this video stands as an option in selected cases of indirect CCF.