The treatment of carotid cavernous fistulas has undergone a fundamental tra
nsformation during the preceding 30 years. Endovascular techniques have not
only largely replaced surgical management of this disease, but have also r
esulted in substantially lower rates of procedure-associated morbidity and
mortality. Percutaneous transarterial occlusion of direct cavernous carotid
fistulas with preservation of the carotid artery using detachable balloons
is now considered the current preferred therapeutic objective. Concurrent
progress in percutaneous transvenous embolization techniques and materials
has led to more effective and better-tailored therapies for indirect (dural
) carotid cavernous fistulas. The current understanding of the clinicopatho
logic mechanisms associated with carotid cavernous fistulas and the endovas
cular therapies used in the contemporary management of this condition are r
eviewed.