Transvenous detachable coil embolization of direct & high-flow carotid-cavernous fistula. Alternative of transarterial detachable balloon embolization.

We encountered 8 cases of high-flow and direct carotid cavernous fistula (CCF) since 1994. Four patients were treated with transarterial fistula occlusions using detachable balloons before 1997. Complete obliteration of CCFs with preservation of internal carotid artery (ICA) were achieved in all 4 cases using each one balloon. Three cases were approached to the fistulas via the percutaneous transfemoral approach, but one aged patient needed a direct carotid puncture because of her tortuous vessels. Meanwhile, transvenous embolizations with detachable coils (DCs); Guglielmi detachable coil (GDC), interlocking detachable coil (IDC) and fibered platinum coil were attempted in four cases after 1997; in 2 cases after failure of transarterial approach and in 2 as initial form of treatment. All 4 cases were successfully approached to the cavernous sinuses (CS) through the inferior petorosal sinus (IPS). At first we intended to block dangerous outflow points for the superior ophthalmic vein (SOV), cortical venous reflux (CVR) and contra-lateral CS. And then obliteration of the fistulas were performed with tight packing of GDCs covering the outside of the ICA. At this time, the arteriovenous shunts were disappeared abruptly, so we finished all procedure without occlusion of IPS.We compared the two methods and concluded that the transvenous embolizaton with DCs is an useful alternative of transarterial detachable balloon therapy of high flow CCF, especially when transarterial approach is difficult or proper balloons are not available.