Endoscopic Endonasal Approach for Salvage Embolization of Indirect Carotid-Cavernous Fistula: 2-Dimensional Operative Video

Left untreated, symptomatic carotid-cavernous fistulae (CCFs) pose risk of vision compromise and thus require prompt treatment. The development of endovascular techniques has revolutionized the way CCFs are treated and is the gold standard.(1,2) However, variations in CCF development and response to treatment leads to nuance. Furthermore, failed endovascular embolization has led to alternative approaches being used.(3-6) We present a 34-year-old man who developed decreased left visual acuity and proptosis found to have an indirect CCF. His left initial intraocular pressure (IOP) was 25 mm Hg and acuity was 20/50. Initial angiography demonstrated the indirect CCF with prominence of the superior ophthalmic vein. Transvenous endovascular access failed because of venous tortuosity and instead, the patient first underwent anterior orbitotomy for direct cannulization of the superior ophthalmic vein for fistula embolization. However, the fistula recanalized through the inferior ophthalmic and facial veins with worsening of symptoms and IOP (29mmHg). The patient was taken to a hybrid operating roomfor initial attempted inferior ophthalmic cannulization, which failed, and then the salvage endoscopic endonasal approach for direct coagulation and embolization of the cavernous sinus with Surgifoam (Johnson & Johnson; New Brunswick). The patient consented to the procedure and to the publication of his image. He did well postoperatively, and at 3-month follow-up, his IOP was 16mmHg, proptosis improved, and vision was 20/20. With failure of several alternate treatments, direct cavernous sinus access may be necessary, and the endonasal route provides a unique corridor which avoids transgression of cranial nerves.