A Non-Traditional Approach to the Management of Carotid Cavernous Fistula: A Case Report

ABSTRACT: Introduction: Carotid-cavernous fistula (CCF) is an aberrant flow from the carotid artery and its branches into the cavernous sinus, which can be either direct or indirect. Acute ocular congestion, cranial nerve dysfunction, and orbital bruits are common symptoms of direct CCFs, which are primarily traumatic but can also occur spontaneously. This article details two direct CCF cases in which transvenous coil embolization was successfully performed after failure of transarterial access. Case Presentation: We report two patients, a man aged 53 and a woman aged 69, each presenting with acute unilateral ocular signs, including exophthalmos, conjunctival chemosis, and an audible orbital bruit. Cranial nerve involvement was observed in both patients, with no characteristic vision loss. Digital subtraction angiography revealed direct high-flow CCFs that drained mostly into orbital venous channels and originated from the intracavernous internal carotid artery. Due to poor architecture and high- flow dynamics, trans-arterial catheterization of the fistulous site was not possible in either patient. Consequently, a transvenous technique was used to repair each fistula, passing into the inferior petrosal sinus and filling the cavernous sinus with coils until total occlusion was attained. Imaging following embolization verified complete shunt closure while maintaining ICA patency. Both patients experienced immediate relief of ocular congestion, elimination of bruits, and progressive normalization of cranial nerve function. Discussion: These two cases demonstrate the difficulties in diagnosing direct CCFs, which might have both spontaneous and traumatic- anatomical causes. Transvenous coil embolization provides a safe and efficient alternative when arterial access is limited by anatomical constraints or high-flow dynamics. Relief in neurological and ocular conditions of both patients highlighted the effectiveness of the said method. Conclusion: For direct CCFs, transvenous coil embolization is a useful treatment option, especially if transarterial access is speculative. Excellent clinical outcomes and complete symptom relief may result from early detection and tailored endovascular care. Keywords: Carotid–cavernous fistula, Direct CCF, Transvenous embolization, Coil embolization, Cavernous sinus