Endoscopic transorbital approach to managing indirect carotid cavernous fistula: A novel technique.

Background: Carotid cavernous fistula (CCF) is a rare vascular shunt between the carotid artery and the cavernous sinus, leading to venous hypertension and occasionally cortical venous reflux. It is primarily treated with endovascular therapy. However, transvenous or transarterial endovascular access may be difficult in some cases and may fail to obliterate the fistula. We describe the first case of utilizing the endoscopic transorbital approach (ETOA) to directly obliterating the CCF. Case Description: A 65-year-old man presented with the left eye blurring of vision for 2 months. He was diagnosed with the left Barrow type D indirect CCF with cortical venous reflux on digital subtraction angiogram. Primary transvenous embolization failed due to thrombosed venous access. Thus, we employed ETOA through a lid crease incision, lateral orbitotomy, and drilling of the sphenoid wing to access the cavernous sinus. Direct cannulation of the cavernous sinus was attempted. Ultimately, we injected hemostatic agents including Floseal to directly obliterate the CCF. Postoperative and follow-up digital subtraction angiogram showed complete obliteration. This is the first case of endoscopic-assisted transorbital approach to direct obliteration of a CCF. This approach allows for a smaller wound, less morbidity for complex cases with difficult venous access, with potential for complete obliteration. Conclusion: We illustrate the novel use of ETOA to direct obliteration of a complex CCF.