Orbital approaches for treatment of carotid cavernous fistulas: A systematic review

• Published in: World neurosurgery Vol. 96; pp. 243 - 251
• Main Authors: Phan, Kevin, BSc, M Phil, Xu, Joshua, BSc, Leung, Vannessa, MBBS, Teng, Ian, B Med, Sheik-Ali, Sharaf, Maharaj, Monish, B Med, Mobbs, Ralph, MBBS, MS, FRACS, Rao, Prashanth J., MBBS, FRACS, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.12.2016
• Subjects: Carotid cavernous fistula; Carotid-Cavernous Sinus Fistula - surgery; Databases, Bibliographic - statistics & numerical data; Embolization; Embolization, Therapeutic - methods; Humans; Neurosurgery; Orbit - surgery; Orbital approach; Outcome; Systematic review; Transvenous; superior ophthalmic vein; embolization; transvenous; CCF; inferior petrosal sinus; systematic review; IPS; IOV; inferior ophthalmic vein; carotid cavernous fistula; MOV; SOV; medial ophthalmic vein; orbital approach; outcome; Orbital approach; Outcome; Embolization; Systematic review; Carotid cavernous fistula; Transvenous
• DOI: 10.1016/j.wneu.2016.08.087
• ISSN: 1878-8750

Abstract Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid arteries and the cavernous sinus. CCFs often present with double vision, reduced visual acuity and conjunctivitis. Deteriorating ocular symptoms due to abnormal fistula drainage can potentially cause permanent blindness, and so urgent interventional treatment is necessary. Transvenous embolization of the fistula is the primary treatment option for the majority of patients with symptomatic CCFs. Orbital approaches are considered to be risky compared to the traditional approach via the inferior petrosal sinus, and is thus used as a secondary option. These include embolization via the superior ophthalmic vein (SOV), inferior ophthalmic vein (IOV), medial ophthalmic vein (MOV) and direct transorbital puncture. This study aims to assess the merits and risks of orbital approaches in transvenous embolization of CCFs. A systematic review of thirty studies assessing the radiographic and clinical outcomes of this approach was conducted. Outcomes of interest include successful fistula closure, postoperative improvement of ocular symptoms and complications from the procedure. Weighted averages were calculated for all outcomes. Transvenous embolization via an orbital approach had a high success rate (89.9%). Improvement in visual acuity and proptosis was found in 93.4% and 88.1% of patients respectively. There were no major complications. Minor complications found include subconjunctival haemorrhage (n=4), intra-orbital haemorrhage (n=1), eyelid hematoma (n=1) and foreign-body granuloma (n=3). In conclusion, all orbital approaches for transvenous embolization of CCFs are effective and safe.