LAUSR

Background Carotid-cavernous fistulas (CCFs) are abnormal communications between the arterial and venous circulation within the cavernous sinus, manifesting in myriad neurological and ophthalmological sequalae. In rare circumstances patients' unique vascular anatomies preclude standard endovascular treatment for this pathology, warranting combined surgical and endovascular approaches wherein the cavernous sinus is accessed via superior ophthalmic vein (SOV) exposure, cutdown, and cannulation. Case Description We describe 3 cases of CCF treated at our quaternary neurovascular referral center between 2017 and 2019. The first is a 35-year-old man with symptomatic, traumatic, right-sided CCF, treated with endovascular therapy (transarterial detachable balloon placement). The other cases were treated with contrasting surgical and endovascular combined approaches because of unique vascular challenges. The second is a 71-year-old woman with spontaneous right-sided CCF whose carotid sinus was accessed and embolized through a transpalpebral cutdown of the SOV. The third case is a 70-year-old man with symptomatic, spontaneous bilateral CCF. After unsuccessful transarterial and transvenous endovascular approaches, transorbital (intracranial) SOV cutdown and cannulation were performed to embolize the shunting fistula. Conclusions Endovascular approaches are well described as the mainstay of treatment for CCF but are not possible for all patients. In circumstances where individual vascular anatomy is not amenable to transarterial or transvenous access or embolization, a combined surgical and endovascular approach may be appropriate. We describe 3 cases that illustrate the spectrum of interventions for CCF, as well as the technical aspects of treatment for 2 patients with complex, direct CCF, using an embolization approach reliant on SOV cutdown and cannulation.