279 Bail Out No Longer: Direct Puncture of the Cavernous Sinus is More Likely to Cure Indirect Carotid Cavernous Fistulae With Shorter Procedure Time

INTRODUCTION: Indirect carotid cavenrous fistulae are traditionally treated via transvenous embolization, however, the complex anatomy of the cavernous sinus and high-flow venopathy can render endovascular treatment an arduous task. METHODS: Clinical and technical variables were extracted from the medical record. Procedural video was maintined in a dedicated database. RESULTS: Of 98 total cases, transorbital direct puncture of the cavernous sinus was performed in 34 cases (35%). Since 2019, treatment approach and embolysate utilized has dramatically changed. In the last 21 primary treatments, 12(57%) were by direct puncture vs 19 of the previous 74(26%, p = 0.097). EVOH was used in 17(81%) of the last 20 primary treatments vs 9 of the previous 74(12%, p< 0.001). After primary treatment without adjuvant epsilon-aminocaproic acid, the complete obliteration rate after direct puncture using any embolysate was significantly higher than transvenous embolization (30/34 or 88%, 47/62 or 76%, p=0.001). Complete first attempt obliteration was 100% (11 of 11) for patients treated with EVOH via the transorbital route. The median fluoroscopy time in the 11 cases of transorbital puncture using EVOH was 46 minutes as compared to 137 for matched patients who underwent transvenous embolization (p<0.001). Clinical follow-up of at least 1 month was obtained in 84 patients (87%; median 2 months; IQR 1,12; range 1-165 months). Symptoms were improved in 72, stable in 11 and worse in 1 patient. Significant technical or permanent neurological complications occurred in 2 (1.9%) and 1 (0.97%), respectively. CONCLUSIONS: Transorbital direct puncture of the cavernous sinus with embolization of indirect CCF using EVOH has resulted in improved first attempt cure rates and reduced fluoroscopy time.