Direct Carotid-Cavernous Fistula due to Aneurysmal Rupture with Residual Aortic Dissection Treated by Coil Embolization via Direct Puncture of the Common Carotid Artery: A Case Report.

Objective: This case report describes the successful coil embolization of a direct carotid-cavernous fistula (d-CCF) caused by aneurysmal rupture in an older patient with residual aortic dissection, via direct puncture of the common carotid artery (CCA). Case Presentation: A 95-year-old woman presented with progressive right periorbital swelling, pain, and eye redness. Cranial imaging revealed proptosis, dilated superior and inferior ophthalmic veins, and a ruptured aneurysm of the right internal carotid artery (ICA), leading to a diagnosis of d-CCF. Conventional endovascular access was not feasible due to residual aortic dissection extending from the brachiocephalic artery to the right CCA, despite prior stent graft placement. Under general anesthesia, a 6-Fr sheath was inserted directly into the distal CCA. Coil embolization was then performed using a balloon-assisted technique, targeting the cavernous sinus and the aneurysm. The procedure successfully occluded the fistula and preserved the ICA flow. Postoperatively, her ocular symptoms improved significantly, and she was discharged 1 week later without complications. Conclusion: This case demonstrates that d-CCF can be safely and effectively treated with careful vascular evaluation and a tailored endovascular strategy, even in extremely old patients with difficult vascular access and complex aneurysmal anatomy.