Carotid cavernous fistula: embolization via a bilateral superior ophthalmic vein approach.

We report the case of a 74-year-old woman with a complex indirect (Barrow D) carotid cavernous sinus fistula. The patient was treated incrementally and finally cured by a rarely reported bilateral retrograde direct transvenous approach via the superior ophthalmic vein. The treatment of the complex carotid cavernous fistula with multiple bilateral fistula points showed additional complexity due to a partially thrombosed left superior ophthalmic vein, which required a combined microsurgical and endovascular treatment, showing that treatment can be achieved, if necessary, by catheterization of a thrombosed orbital vein.