Percutaneous transfemoral embolization of an indirect carotid-cavernous fistula with cortical venous access to the cavernous sinus

The authors present the case of a 61-year-old man with an indirect carotid- cavernous fistula (CCF). Many now advocate a primary transvenous approach t o deal with such lesions, with packing and thrombosis of the cavernous sinu s leading to fistula obliteration. Transvenous access to the cavernous sinu s via the inferior petrosal sinus is the usual route of access; both surgic al and transfemoral superior ophthalmic vein approaches are also well descr ibed. In the case presented, the anatomy of the CCF was unfavorable for the se approaches and its dominant venous egress was via a single enlarged arte rialized cortical vein. The cavernous sinus was accessed with a transfemora l retrograde approach to the cortical draining vein. Successful CCF emboliz ation was documented radiographically and clinically. To the authors' knowl edge, this procedure has not been previously described in the English liter ature.