365 Comparison of the Transarterial, Transvenous, and Superior Ophthalmic Vein Approaches in the Treatment of Indirect Cavernous-Carotid Fistulas (CCFs)

INTRODUCTION: Indirect Carotid-Cavernous Fistulas (CCFs) are abnormal arteriovenous shunting lesions with a highly variable clinical presentation that depends on the drainage pattern. Based on venous drainage, treatment can be either transarterial or transvenous. METHODS: We conducted a retrospective analysis of 74 patients admitted to our institution from 2010 to 2023 with the diagnosis of 77 indirect CCFs as confirmed on digital subtraction angiography. RESULTS: A total of 74 patients with 77 indirect CCFs were included in this study. Embolization was performed via the transarterial (TA) approach in 4 patients, the transvenous (TV) approach in 50 patients, and the superior ophthalmic vein (SOV) in 23 cases. At the end of the procedure, complete occlusion was achieved in 56 (72.7%) cases. The rate of complete occlusion at the end of the procedure and at the last radiological follow-up was significantly higher in the SOV and TV cohorts compared to the TA cohort. The rate of recurrence was highest in the TA cohort (25% TA vs 5.3% TV vs 0% SOV, p=.68). CONCLUSIONS: The rate of immediate complete occlusion was higher in the TV and SOV cohort compared to the TA cohort while the rate of complete occlusion at final follow-up was highest in the SOV cohort. The SOV approach is significantly associated with higher rates of post-op complications. Indirect cavernous-carotid fistulas require careful examination of the fistulous point and the venous drainage to provide the most effective patient-tailored approach.