Endoscopic Transorbital Approach for Endovascular Access to the Cavernous Sinus in Carotid-Cavernous Fistula: A Case Report.

Carotid-cavernous fistulas (CCF) are indirect or direct vascular shunts between vessels of the cavernous sinus and the carotid artery. While indirect CCFs have high rates of spontaneous resolution, direct CCF cases can result in significant orbital and neurological sequelae. This case describes a 75-year-old male patient presenting with acute subarachnoid hemorrhage secondary to a Barrow type-D CCF. Digital subtraction angiography revealed dual arterial supply of the CCF from both the left and right internal carotid artery. Transvenous access for coiling could not be achieved due to vessel tortuosity. Thus, the authors used an endoscopic transorbital approach to directly puncture the cavernous sinus through the superior orbital fissure. This approach allowed for direct visualization of the lateral cavernous sinus and enabled endovascular maneuvrability and coiling. There was a reduction but residual flow post CCF coiling due to microcatheter kickback preventing posterior embolization. Persistent CCF necessitated a craniotomy to allow sufficient access for complete obliteration. At 6-week postcoiling, there was resolution of proptosis and full extraocular movements. This approach has been described in cadaveric studies, with this case demonstrating the first application of this technique in vivo for CCF.