Embolization of Direct Carotid Cavernous Fistula With Onyx and Coils Under Transarterial Balloon Protection

Endovascular management with good preservation of the internal carotid artery (ICA) has become the first-line choice for the treatment of direct carotid cavernous fistulas (CCFs). Multiple treatments have been tried with variable success. This article elucidates the effectiveness and safety of embolization with Onyx and coils under transarterial balloon protection.

We reviewed 18 cases with direct CCFs in our case library. All cases were treated with transarterial or transvenous embolization with Onyx and coils under intra-arterial balloon protection.

Immediate angiography after embolization showed total occlusions in 16 patients and small residual fistulas in 2 patients. Good preservation of the ICA was observed in all cases. The average volume of Onyx was 2.6 ml, and the average length of bare coils was 102.0 cm. Hydrogel-coated coils with an average length of 75.2 were used in five cases. Angiographic follow-ups of 16 patients showed no residual or recurrent fistula within 8 months (average 3.4). For the 2 patients with small residual fistulas, both received short-time angiographic follow-up within 3 month after the procedure. All follow-up angiograms showed no residual or recurrent fistula. Clinical follow-up of the other two recent patients showed no relapsing symptoms. There were no procedure-related complications, and no new symptoms occured in any patient.

The technique of embolization using Onyx and coils under intra-arterial balloon protection is feasible for the treatment of direct CCFs, especially for patients with large fistula ostium and large cavernous sinus. This technique is an effective and safe option with rare complications.