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Case series
Mid- and long-term outcomes of carotid-cavernous fistula endovascular management with Onyx and n-BCA: experience of a single tertiary center
  1. Sean M Barber1,
  2. Leonardo Rangel-Castilla1,
  3. Y Jonathan Zhang1,
  4. Richard Klucznik2,
  5. Orlando Diaz2
  1. 1Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
  2. 2Department of Interventional Neuroradiology, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
  1. Correspondence to Dr Sean M Barber, Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, 6560 Fannin St 944, Houston, TX 77030, USA; smbarber{at}


Introduction Endovascular therapy is the preferred treatment for most carotid-cavernous fistulas (CCFs). Early reports have documented excellent initial clinical and radiographic outcomes after embolization of CCFs with Onyx or n-butyl cyanoacrylate (n-BCA), but little evidence is available about the long-term durability of this technique.

Objective To characterize the long-term durability of CCF liquid embolization.

Methods The authors retrospectively reviewed a database of 24 CCFs in 21 consecutive patients who underwent Onyx or n-BCA embolization of a CCF from 2006 to 2013 at our institution.

Results A total of 25 Onyx or n-BCA embolization procedures were attempted and 24 successfully completed during the study, resulting in complete or near-complete occlusion by the end of the study in all 24 CCFs (obliteration success, 100%). Attempted embolization in a single CCF failed initially, but was performed successfully at a later date by a different approach. None of the 24 CCFs recanalized, regrew, or required any further treatment subsequent to Onyx or n-BCA embolization throughout a mean 12.4 months of angiographic follow-up (range 1–36 months). Clinically significant complications were seen in three embolization procedures, including cranial nerve palsies (n=1), embolic infarct (n=1), and intraperitoneal hemorrhage (n=1).

Conclusions Early evidence has indicated that endovascular embolization with Onyx is relatively safe and effective at achieving an initial angiographic cure for CCFs. Results of our series suggest that angiographic and clinical outcomes of Onyx and n-BCA embolization remain stable at mid- and long-term follow-up.

  • Arteriovenous Malformation
  • Angiography
  • Brain
  • Fistula
  • Liquid Embolic Material

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