title: The superior ophthalmic vein approach for the treatment of carotid-cavernous fistulas: a novel technique using Onyx.
abstract: OBJECTIVE
  Endovascular therapy is the primary treatment option for carotid-cavernous fistulas (CCFs). Operative cannulation of the superior ophthalmic vein (SOV) provides a reasonable alternative route to the cavernous sinus when all transvenous and transarterial approaches have been unsuccessful. The role of the liquid embolic agent Onyx in the management of CCFs has not been well documented, especially when using an SOV approach. The purpose of this study is to assess the safety and efficacy of Onyx embolization of CCFs through a surgical cannulation of the SOV.
  
  
  METHODS
  The authors retrospectively reviewed all patients with CCFs who were treated with Onyx through an SOV approach between April 2009 and April 2011. Traditional endovascular approaches had failed in all patients.
  
  
  RESULTS
  A total of 10 patients were identified, 1 with a Type A CCF, 5 with a Type B CCF, and 4 with a Type D CCF. All fistulas were embolized in 1 session. Onyx was the sole embolic agent used in 7 cases and was combined with coils in 3 other cases. Complete obliteration was achieved in 8 patients and a significant reduction in fistulous flow was achieved in 2 patients, which later progressed to near-complete occlusion on angiographic follow-up. All patients experienced a complete clinical recovery with excellent cosmetic results and were free from recurrence at their latest clinical follow-up evaluations.
  
  
  CONCLUSIONS
  Onyx embolization is an excellent therapy for CCFs in general, and through an SOV approach in particular. Direct operative cannulation of the SOV followed by Onyx embolization may be the best treatment option in patients with CCFs when all other endovascular approaches have been exhausted.
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania 19107, USA.
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Dumont
authors.forename: Stavropoula
authors.initials: S
authors.lastname: Tjoumakaris
authors.forename: L Fernando
authors.initials: LF
authors.lastname: Gonzalez
authors.forename: Jurij R
authors.initials: JR
authors.lastname: Bilyk
authors.forename: Ciro
authors.initials: C
authors.lastname: Randazzo
authors.forename: David
authors.initials: D
authors.lastname: Hasan
authors.forename: Richard T
authors.initials: RT
authors.lastname: Dalyai
authors.forename: Robert
authors.initials: R
authors.lastname: Rosenwasser
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
mesh_terms: D000328:Adult; D000368:Aged; D015901:Angiography, Digital Subtraction; D020216:Carotid-Cavernous Sinus Fistula / Q000175:diagnosis / Q000628:therapy*; D004121:Dimethyl Sulfoxide / Q000627:therapeutic use*; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009915:Orbit / Q000601:surgery; D011145:Polyvinyls / Q000627:therapeutic use*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014683:Vena Cava, Superior / Q000601:surgery*
chemical_list: C450660:Onyx copolymer; D011145:Polyvinyls; D004121:Dimethyl Sulfoxide