Onyx Embolization of Carotid-Cavernous Fistulas and Its Impact on Intraocular Pressure and Recurrence: A Case Series

Abstract

BACKGROUND Carotid-cavernous fistulas (CCFs) are acquired pathological shunting lesions between the carotid artery and the cavernous sinus leading to elevated intraocular pressure (IOP). CCFs are commonly treated via endovascular embolization, which theoretically restores physiological pressure differentials. OBJECTIVE To present our institutional data with CCF treated with embolization and discuss endovascular routes, recurrence rates, and dynamic IOP changes. METHODS Retrospective analysis of 42 CCF patients who underwent Onyx (Covidien, Irvine, California) embolization and pre- and postoperative IOP measurement at a single institution. RESULTS CCFs were 19.0% direct (type A) and 81.0% indirect (types B, C, or D). Onyx-18 liquid embolisate was used during all embolizations. Overall rate of total occlusion was 83.3% and was statistically similar between direct and indirect fistulas. Preoperative IOP was elevated in 37.5%, 100.0%, 75.0%, and 50% in type A, B, C, and D fistulas, respectively. Average ΔIOP was −7.3 ± 8.5 mmHg (range: −33 to +8). Follow-up time was 4.64 ± 7.62 mo. Full angiographic occlusion was a predictor of symptom resolution at 1 mo (P = .026) and 6 mo (P = .021). Partial occlusion was associated with persistent symptoms postoperatively at 1 mo (P = .038) and 6 mo follow-up (P = .012). Beyond 6 mo, negative ΔIOP was associated with continued symptom improvement. Recurrence occurred in 9.5% of patients, all of which were indirect CCFs. CONCLUSION Onyx embolization of CCF is an effective treatment for CCF and often results in the reversal of IOP elevation. Full occlusion predicts favorable clinical outcomes up to 6 mo. Postoperative IOP reduction may indicate favorable long-term clinical outcomes.

Radiation Exposure During Diagnostic and Therapeutic Angiography of Carotid-cavernous Fistula

“…Cerebral angiography is the gold standard for definitive diagnosis, classification and therapeutic planning [1]. Recent advances in endovascular technology have expanded the range of treatment options for CCFs and favorable long-term outcomes have been achieved [2][3][4]. As a result, the mainstay of treatment for CCFs consists of transarterial or transvenous embolization.…”

Challenging Management of an Acute Traumatic Carotid-Cavernous Fistula in a 2-Year-Old Child with Literature Review

“…Maintaining the parent artery is important; however, when this is not possible, trapping the parent artery may provide an alternate option when appropriate collaterals exist. 14 15…”

Comparison of the transarterial, transvenous, and superior ophthalmic vein approaches in the treatment of indirect carotid-cavernous fistulas

“…6 Endovascular embolization with liquid embolic agents, coils, and particles has become the mainstay of treatment for CCFs with high rates of occlusion and effective relief of symptoms. 7,8 Transarterial (TA) embolization of CCFs is the most common treatment for type A CCFs given their high-flow nature and direct arterial access to the fistulous point. 9 Indirect fistulas, alternatively, are more amenable to transvenous (TV) embolization secondary to their higher number of tortuous arterial pedicles with lower flow access to the…”