Background: Cavernous carotid fistulas (CCF) are complex vascular lesions. Treatment via venous approach has been previously described and is highly dependent on the patency of the drainage pathways. The use of unilateral approach to bilateral shunts is challenging. We reviewed our experience with unilateral approach to both cavernous sinuses to treat shunts according to anatomical compartments, to achieve anatomical cure.

Methods We retrospectively reviewed our experience with CCFs. Patients included in this study presented with either bilateral or unilateral shunts with bilateral venous drainage. We used a trans-arterial guiding catheter for road mapping and control angiography. A venous tri-axial system was used to achieve support for distal navigation across the midline via the coronary sinus to the contralateral cavernous sinus. Coils were favored for embolization.

Results All patients presented with ocular symptoms due to cavernous sinus elevated pressure. All had pial venous reflux. Three had indirect CCF and 1 had a direct high flow fistula inducing symptomatic brain stem venous hypertension. Three patients underwent complete occlusion in a single session. One patient required complimentary trans arterial embolization. In one patient despite successful unilateral approach to?bilateral cavernous sinuses, an additional trans ophthalmic vein approach was necessary to obliterate the anterior compartment. No complications were encountered. Early improvement of the ocular signs with complete long-term resolution were observed. Early clinical improvement of the brainstem symptoms was noted within 3 days after complete angiographic obliteration.

Conclusion Careful inspection of the venous anatomy and fistulization sites is critical when treating bilateral CCFs. The contralateral venous route can serve as a safe approach when visualized. Different compartments in the cavernous sinus may require different approaches. Crossing the midline via anterior or posterior coronary sinuses is feasible and efficacious. Limitations may be encountered crossing the midline or navigating anteriorly or posteriorly, and may require complementary approach.

Disclosures: E. Nossek: 2; C; Rapid Medical. D. Chalif: None. A. Setton: None.