Transarterial Embolization of Direct Carotid Cavernous Fistulas with the Double-balloon Technique

Treatment of direct carotid cavernous fistulas (CCF) has progressed from surgical ligation to surgical trapping to endovascular techniques. Endovascular therapies are advantageous as they allow for occlusion of the fistula whilst preserving flow in the parent carotid artery. However, technical difficulties are not uncommon and occur when the fistulous orifice is too small or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Both circumstances may lead to technical failure or an unplanned sacrifice of the parent internal carotid artery (ICA). Here we describe a double-balloon technique used in the embolization of CCF in four patients that were successfully treated with complete immediate occlusion whilst preserving the parent ICA.