A retrospective analysis of 38 carotid cavernous fistula patients treated with balloon-assisted endovascular fistula embolization through simultaneous transarterial and transvenous approaches

Objective: Routine embolization is not completely effective for patients with complicated traumatic carotid cavernous fistula. The aim of this study is to evaluate the clinical outcomes and factors affecting the complications in balloon-assisted Onyx 18 embolization implemented through transarterial and transvenous approaches. Methods: 38 patients who were not suitable for detachable balloon embolization or underwent the embolization but were not cured or relapsed were selected for the study. They were treated by injecting Onyx 18 through two micro-catheters inserted cavernous sinus through transarterial and transvenous approaches. Results: Angiograms taken immediately after the embolization showed that the arteriovenous fistulas disappeared completely in all the patients. Internal carotid artery occlusion was observed in one patient due to Onyx diffusion into the carotid artery. In another patient, small amount of Onyx was washed to the M4 segment of middle cerebral artery by the blood. In other two patients, the glue floated on the arterial wall of internal carotid. After surgery, five (23.7%) patients showed new symptoms of oculomotor nerve damage. During the follow-up period, 77.3% of the patents had normal oculomotor nerve function, and the recovery speed was found not related to the injection dose or oculomotor nerve injury prior to the operation. Conclusion: Simultaneous transarterial and transvenous approach is effective and safe for TCCF patients who are not suitable for detachable balloon embolization or are difficult to treat with the embolization. During the surgical procedure, micro-catheters should be precisely positioned with minimal injection of Onyx 18 to reduce complications.