title: Orbital Approaches for Treatment of Carotid Cavernous Fistulas: A Systematic Review.
abstract: BACKGROUND
  Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid arteries and the cavernous sinus. CCFs often present with double vision, reduced visual acuity, and conjunctivitis. Deteriorating ocular symptoms caused by abnormal fistula drainage can cause permanent blindness, and so urgent interventional treatment is necessary. Transvenous embolization of the fistula is the primary treatment option for most patients with symptomatic CCFs. Orbital approaches are considered to be risky compared with the traditional approach via the inferior petrosal sinus and are thus used as a secondary option. These approaches include embolization via the superior ophthalmic vein, inferior ophthalmic vein, and medial ophthalmic vein and direct transorbital puncture. This study aims to assess the merits and risks of orbital approaches in transvenous embolization of CCFs.
  
  
  METHODS
  A systematic review of 30 studies assessing the radiographic and clinical outcomes of this approach was conducted. Outcomes of interest included successful fistula closure, postoperative improvement of ocular symptoms, and complications from the procedure. Weighted averages were calculated for all outcomes.
  
  
  RESULTS
  Transvenous embolization via an orbital approach had a high success rate (89.9%). Improvement in visual acuity and proptosis was found in 93.4% and 88.1% of patients, respectively. There were no major complications. Minor complications found included subconjunctival hemorrhage (n = 4), intraorbital hemorrhage (n = 1), eyelid hematoma (n = 1), and foreign-body granuloma (n = 3).
  
  
  CONCLUSIONS
  All orbital approaches for transvenous embolization of CCFs are effective and safe.
authors: NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia; University of New South Wales (UNSW), Sydney, Australia; University of Sydney, Sydney, Australia. Electronic address: kpha5955@uni.sydney.edu.au.
authors: Kevin
authors: K
authors: Phan
authors: NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia; University of Sydney, Sydney, Australia.
authors: Joshua
authors: J
authors: Xu
authors: University of New South Wales (UNSW), Sydney, Australia.
authors: Vannessa
authors: V
authors: Leung
authors: NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia; University of New South Wales (UNSW), Sydney, Australia.
authors: Ian
authors: I
authors: Teng
authors: Barts and The London School of Medicine and Dentistry, London, United Kingdom.
authors: Sharaf
authors: S
authors: Sheik-Ali
authors: NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia; University of New South Wales (UNSW), Sydney, Australia.
authors: Monish
authors: M
authors: Maharaj
authors: NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.
authors: Ralph
authors: R
authors: Mobbs
authors: NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia; University of New South Wales (UNSW), Sydney, Australia.
authors: Prashanth J
authors: PJ
authors: Rao
mesh_terms: D020216:Carotid-Cavernous Sinus Fistula / Q000601:surgery*; D016206:Databases, Bibliographic / Q000706:statistics & numerical data; D004621:Embolization, Therapeutic / Q000379:methods*; D006801:Humans; D009915:Orbit / Q000601:surgery*
keywords: Carotid cavernous fistula; Embolization; Orbital approach; Outcome; Systematic review; Transvenous