Shifting Paradigms of Endovascular Therapies for Cavernous Carotid Fistulas

Abstract

avernous carotid fistulas (CCFs) represent abnormal shunts between the cavernous sinus and its arterial C inflow. The wide heterogeneity of the pathology that underlies CCFs, and their associated clinical severity, has made their evaluation and treatment exceptionally challenging. The earliest attempt to surgically treat a CCF is attributed to Benjamin Travers in 1811, who directly ligated the ipsilateral common carotid artery in a patient suffering from a “cirsoid aneurysm of the orbit” (3). In 1931 Brooks and Gardner used muscle to pack the venous side of direct fistulas through their opening in the carotid artery (3). Such attempts often ultimately required ligation of the ipsilateral common or cervical internal carotid artery (ICA), a technique that was fruitful in only 30% 50% of cases (17). These early attempts to mitigate the effects of CCFs were hampered by inadequate imaging techniques necessary to understand the underlying the disease processes. By 1934, Terry and Mysel (19) were the first to leverage the newly developed technique of cerebral angiography to provide the insight of “pulsating exophthalmos,” efforts that decades later culminated in establishing digital subtraction angiography as the gold standard in imaging CCFs.