{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,30]],"date-time":"2026-05-30T09:05:57Z","timestamp":1780131957907,"version":"3.54.0"},"reference-count":50,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,3]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Indirect carotid-cavernous fistulas (CCFs) are abnormal arteriovenous shunting lesions with a highly variable clinical presentation that depends on the drainage pattern. Based on venous drainage, treatment can be either transarterial (TA) or transvenous (TV). The aim of this study was to compare the outcomes of indirect CCF embolization via the TA, TV, and direct superior ophthalmic vein (SOV) approaches.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n The authors conducted a retrospective analysis of 74 patients admitted to their institution from 2010 to 2023 with the diagnosis of 77 indirect CCFs as confirmed on digital subtraction angiography.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n A total of 74 patients with 77 indirect CCFs were included in this study. Embolization was performed via the TA approach in 4 cases, the TV approach in 50 cases, and the SOV in 23 cases. At the end of the procedure, complete occlusion was achieved in 76 (98.7%) cases. The rate of complete occlusion at the end of the procedure and at last radiological follow-up was significantly higher in the SOV and TV cohorts than in the TA cohort. The rate of recurrence was highest in the TA cohort (25% for TA vs 5.3% for TV vs 0% for SOV, p = 0.68).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n The rate of immediate complete occlusion was higher in the TV and SOV cohorts than in the TA cohort while the rate of complete occlusion at final follow-up was highest in the SOV cohort. The SOV approach was significantly associated with higher rates of postoperative complications. Indirect CCFs require careful examination of the fistulous point and the venous drainage to provide the most effective patient-tailored approach.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2023.12.focus23776","type":"journal-article","created":{"date-parts":[[2024,3,1]],"date-time":"2024-03-01T07:01:02Z","timestamp":1709276462000},"page":"E7","source":"Crossref","is-referenced-by-count":1,"title":["Comparison of the transarterial, transvenous, and superior ophthalmic vein approaches in the treatment of indirect carotid-cavernous fistulas"],"prefix":"10.3171","volume":"56","author":[{"given":"Kareem","family":"El Naamani","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikolaos","family":"Mouchtouris","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shyam","family":"Majmundar","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Sah","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anand","family":"Kaul","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Saman","family":"Sizdahkhani","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arbaz A.","family":"Momin","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marc","family":"Ghanem","sequence":"additional","affiliation":[{"name":"School of Medicine, Lebanese American University, Beirut, Lebanon;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fadi","family":"Al Saiegh","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, UT Health San Antonio, Texas; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M. Reid","family":"Gooch","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nabeel A.","family":"Herial","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert H.","family":"Rosenwasser","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stavropoula I.","family":"Tjoumakaris","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jurij R.","family":"Bilyk","sequence":"additional","affiliation":[{"name":"Department of Oculoplastic and Orbital Surgery, Wills Eye Hospital, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pascal","family":"Jabbour","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"11","key":"b1","series-title":"Acta Neurochir (Wien)","first-page":"1149","article-title":"Trans-arterial embolisation therapy of dural carotid-cavernous fistulae using low concentration n-butyl-cyanoacrylate","volume":"150","author":"Li MH","year":"2008","unstructured":"Li MH, Tan HQ, Fang C, Trans-arterial embolisation therapy of dural carotid-cavernous fistulae using low concentration n-butyl-cyanoacrylate. Acta Neurochir (Wien). 2008;150(11):1149\u20131156."},{"key":"b2","series-title":"Cesk Slov Oftalmol","article-title":"Carotid-cavernous fistula from the perspective of an ophthalmologist. A review","author":"\u010cmelo J","unstructured":"\u010cmelo J. Carotid-cavernous fistula from the perspective of an ophthalmologist. A review. Cesk Slov Oftalmol. Published online August 30, 2020. doi: 10.31348\/2020\/8"},{"key":"b3","series-title":"World Neurosurg","first-page":"338","article-title":"Cavernous-carotid fistula presenting with intracerebral hemorrhage in the absence of ocular symptoms","volume":"137","author":"Mouchtouris N","year":"2020","unstructured":"Mouchtouris N, Lang MJ, Stefanelli A, Cavernous-carotid fistula presenting with intracerebral hemorrhage in the absence of ocular symptoms. World Neurosurg. 2020;137:338\u2013340."},{"issue":"5","key":"b4","series-title":"Neurosurg Focus","first-page":"E9","article-title":"Carotid-cavernous fistulas","volume":"32","author":"Ellis JA","year":"2012","unstructured":"Ellis JA, Goldstein H, Connolly ES Jr, Meyers PM. Carotid-cavernous fistulas. Neurosurg Focus. 2012;32(5):E9."},{"issue":"2","key":"b5","series-title":"J Neurosurg","first-page":"248","article-title":"Classification and treatment of spontaneous carotid-cavernous sinus fistulas","volume":"62","author":"Barrow DL","year":"1985","unstructured":"Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. 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Carotid cavernous fistula (CCF) treatment approaches: a systematic literature review and meta-analysis of transarterial and transvenous embolization for direct and indirect CCFs. Clin Neurol Neurosurg. 2021;204:106601."},{"issue":"Suppl 3","key":"b14","series-title":"J Neurol Surg B Skull Base","first-page":"e278","article-title":"Transvenous Onyx embolization of carotid-cavernous fistulas: mid- and long-term outcomes","volume":"82","author":"Beer-Furlan A","year":"2021","unstructured":"Beer-Furlan A, Joshi KC, Brahimaj B, Lopes DK. Transvenous Onyx embolization of carotid-cavernous fistulas: mid- and long-term outcomes. J Neurol Surg B Skull Base. 2021;82(Suppl 3):e278\u2013e284."},{"issue":"6","key":"b15","series-title":"J Neurosurg","first-page":"1083","article-title":"Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18","volume":"109","author":"Lv X","year":"2008","unstructured":"Lv X, Jiang C, Li Y, Wu Z. 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Published online August 30, 2020. doi: 10.31348\/2020\/8"},{"key":"b3","series-title":"World Neurosurg","first-page":"338","article-title":"Cavernous-carotid fistula presenting with intracerebral hemorrhage in the absence of ocular symptoms","volume":"137","author":"Mouchtouris N","year":"2020","unstructured":"Mouchtouris N, Lang MJ, Stefanelli A, Cavernous-carotid fistula presenting with intracerebral hemorrhage in the absence of ocular symptoms. World Neurosurg. 2020;137:338\u2013340."},{"issue":"5","key":"b4","series-title":"Neurosurg Focus","first-page":"E9","article-title":"Carotid-cavernous fistulas","volume":"32","author":"Ellis JA","year":"2012","unstructured":"Ellis JA, Goldstein H, Connolly ES Jr, Meyers PM. Carotid-cavernous fistulas. 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Transvenous Onyx embolization of carotid-cavernous fistulas: mid- and long-term outcomes. J Neurol Surg B Skull Base. 2021;82(Suppl 3):e278\u2013e284."},{"issue":"6","key":"b15","series-title":"J Neurosurg","first-page":"1083","article-title":"Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18","volume":"109","author":"Lv X","year":"2008","unstructured":"Lv X, Jiang C, Li Y, Wu Z. Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18. J Neurosurg. 2008;109(6):1083\u20131090."},{"issue":"6","key":"b16","series-title":"AJNR Am J Neuroradiol","first-page":"1346","article-title":"Transvenous treatment of spontaneous dural carotid-cavernous fistulas using a combination of detachable coils and Onyx","volume":"27","author":"Suzuki S","year":"2006","unstructured":"Suzuki S, Lee DW, Jahan R, Duckwiler GR, Vi\u00f1uela F. 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