Combined antegrade and retrograde transarterial approaches for embolization of a traumatic carotid‑cavernous fistula with concomitant middle meningeal arteriovenous fistula

Endovascular treatment (EVT) is a useful modality for traumatic carotid‑cavernous fistulas (CCFs); in rare cases, combined antegrade and retrograde transarterial approaches may be applied for embolization of the fistula with concomitant internal carotid artery (ICA) sacrifice and preservation of the ophthalmic artery (OphA). A 62‑year‑old female patient sustained a motor vehicle accident and developed proptosis, chemosis, and congestion in her right eye, while no abnormalities in ocular motility or visual acuity were noted. Computed tomography angiography confirmed the CCF. Under general anesthesia, digital subtraction angiography revealed a right CCF supplied antegradely by the ICA and retrogradely by the posterior communicating artery (PcomA). A left middle meningeal arteriovenous fistula was identified. Access to the basilar artery was established. A microcatheter was retrogradely navigated via the PcomA to reach the proximal ICA across the fistula. Then, another microcatheter was advanced into the cavernous sinus via an antegrade ICA approach. Subsequently, combined antegrade and retrograde transarterial coiling with ICA sacrifice for the CCF was successfully performed. During coiling, the patency of the OphA was monitored through the PcomA microcatheter. Afterwards, the middle meningeal arteriovenous fistula was embolized. At the 1‑month follow‑up, her right eye redness and swelling resolved, and at the 3‑month follow‑up, she had recovered well and returned to her normal status. Therefore, when embolizing the CCF with ICA sacrifice, if the PcomA is well‑developed, the combined antegrade and retrograde transarterial approaches can be used, which may facilitate the obliteration of the CCF and preservation of the OphA.