Direct Ophthalmic Artery Puncture for Coil Embolization of a Traumatic Internal Carotid Artery Pseudoaneurysm With a Concomitant Carotid-Cavernous Fistula Following a Transorbital Penetrating Injury

The coexistence of a traumatic internal carotid artery (ICA) pseudoaneurysm and a carotid-cavernous fistula (CCF) after a transorbital penetrating injury is rare and presents major therapeutic challenges. We report a case of a Denver Grade III traumatic ICA pseudoaneurysm (TICA) with longitudinal arterial dissection, for which reconstructive endovascular treatment was unsuitable; therefore, bypass-assisted ICA trapping was selected as the initial management. Despite parent artery occlusion, postoperative angiography revealed persistent pseudoaneurysmal filling via retrograde collateral inflow from the external carotid system through the ophthalmic artery. The traumatic CCF became angiographically evident after ICA trapping, indicating altered hemodynamics. Both transvenous embolization via the inferior petrosal sinus and retrograde transarterial access through the facial and angular arteries were attempted but failed because of anatomical constraints. As standard strategies could not achieve complete exclusion, controlled surgical access to the ophthalmic artery was selected as the salvage approach. Using the outer cannula of an 18-gauge intravenous catheter as a sheath substitute, a microcatheter was advanced into the pseudoaneurysm, and coil embolization was performed. Complete obliteration of both the pseudoaneurysm and the CCF was achieved without additional neurological deficits. This case demonstrates that direct ophthalmic artery access may serve as a highly selective salvage option in exceptional circumstances when TICA and CCF coexist and conventional approaches are not feasible.