Neurosurg Focus 32 (5):E14, 2012

Treatment of carotid-cavernous fistulas using intraarterial

balloon assistance: case series and technical note
L. Fernando Gonzalez, M.D., Nohra Chalouhi, M.D., Stavropoula Tjoumakaris, M.D.,
Pascal Jabbour, M.D., Aaron S. Dumont, M.D., and Robert H. Rosenwasser, M.D.
Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience,
Philadelphia, Pennsylvania

Object. Multiple approaches have been used to treat carotid-cavernous fistulas (CCFs). The transvenous ap-
proach has become a popular and effective route. Onyx is a valuable tool in today’s endovascular armamentarium.
The authors describe the use of a balloon-assisted technique in the treatment of CCFs with Onyx and assess its fea-
sibility, utility, and safety.
Methods. The authors searched their prospectively maintained database for CCFs embolized using Onyx with
the assistance of a compliant balloon placed in the internal carotid artery (ICA).
Results. Five patients were treated between July 2009 and July 2011 at the authors’ institution. A balloon helped
to identify the fistulous point, served as a buttress for coils, protected from inadvertent arterial embolizations, and pre-
vented Onyx and coils from obscuring the ICA during the course of embolization. No balloon-related complications
were noted in any of the 5 cases. All 5 fistulas were completely obliterated at the end of the procedure. Four patients
had available clinical follow-ups, and all 4 showed reversal of nerve palsies.
Conclusions. Balloon-assisted Onyx embolization of CCFs offers a powerful combination that prevents inad-
vertent migration of the embolic material into the arterial system, facilitates visualization of the ICA, and serves as a
buttress for coils deployed in the cavernous sinus through the fistulous point. Despite adding another layer of techni-
cal complexity, an intraarterial balloon can provide valuable assistance in the treatment of CCFs.
(http://thejns.org/doi/abs/10.3171/2012.2.FOCUS1213)

Key Words      •      Onyx embolization      •      carotid-cavernous fistula      •      balloon assistance

C Methods
arotid-cavernous fistulas are abnormal connec-
tions between the internal, external, or both ca-
rotid arteries and the cavernous sinus.2 This shunt-
ing of blood can lead to ocular venous hypertension and
orbital congestive symptoms. Multiple treatments have
been tried over the years with variable success.9 The en-
dovascular approach has demonstrated safety and durable
efficacy in the treatment of CCFs.9 The use of a nonde-
tachable balloon during Onyx embolization (ev3, Inc.) of
CCFs has been reported in 2 recently published articles,
but the utility and the safety of the technique have not
been investigated.5,10 We present a series of 5 cases in
which a direct or type A CCF2 was treated using a trans-
venous or transarterial approach with simultaneous pro-
tection of the ICA with a nondetachable compliant bal-
loon. We describe this technique and assess its feasibility,
safety, and utility.
Abbreviations used in this paper: CCF = carotid-cavernous
fistula; ICA = internal carotid artery; IPS = inferior petrosal sinus;
SOV = superior orbital vein.
We searched our prospectively maintained database
for all patients with a CCF who underwent Onyx emboli-
zation with the simultaneous use of intraarterial balloons.
All procedures were performed under general endotra-
cheal anesthesia and neurophysiological monitoring us-
ing electroencephalography and somatosensory evoked
potentials. Bilateral femoral access was obtained using
a 7-Fr sheath on the arterial side and a 6-Fr sheath on
the contralateral venous side. After placement of bilat-
eral sheaths, patients were heparinized, and an activat-
ing clotting time was maintained at 2–2.5 times baseline.
Standard cerebral angiography was performed, including
bilateral internal and external carotid arteries as well as
bilateral vertebral angiograms.
The fistula was demonstrated on the arterial run (Fig.
1) and the venous phase was used as a mask to identify
the IPS. A 6-Fr guide catheter was placed at the jugular
bulb, and the IPS was catheterized using an Echelon 10
(ev3, Inc.) as a conduit to the cavernous sinus. A veno-

Neurosurg Focus / Volume 32 / May 2012 1


Fig. 1.  Left ICA (LICA) injection (lateral [left] and anteroposterior
[right] views) showing rapid opacification of the cavernous sinus.
gram was performed in all patients to ascertain that the
microcatheter was positioned proximal to the origin of
the SOV.
At this point, a Hyperglide balloon (ev3, Inc.) was
navigated in the arterial side and was left in a position
spanning the fistulous site. If the fistulous point was not
identified on the ICA angiogram through the guide cathe-
ter, a standard microcatheter was advanced and positioned
distally to the balloon. The balloon was subsequently in-
flated to decrease the high flow through the ICA and to
allow for the identification of the fistulous point on serial
microangiography runs (Fig. 2). Once the fistulous point
was identified (Fig. 3), an attempt was made to access the
cavernous sinus through the fistulous site. When this ap-
proach was unsuccessful, the microcatheter was removed
from the arterial side, and access to the cavernous sinus
was obtained through the IPS. Coils were deployed in the
cavernous sinus transvenously through the IPS or trans-
arterially through the fistulous point using the balloon as
a buttress to prevent coil herniation into the ICA. Once
coils were deployed, Onyx was carefully injected with
the balloon inflated in the ICA (Fig. 4). The balloon was
deflated 2 minutes after interruption of Onyx injection,
allowing time for Onyx solidification. In cases in which
there was still arteriovenous shunting (Fig. 5), the bal-
loon was reinflated and the procedure was continued until
no evidence of early venous drainage was identified from
the arterial injection (Fig. 6). The microcatheters were re-
moved, and a control angiogram was obtained and was
compared with the initial run to rule out embolic events
and confirm complete fistula obliteration.
Fig. 2.  Left ICA injection (anteroposterior [left] and lateral [right]
views) showing with a balloon inflated causing temporary carotid occlu-
sion. The microcatheter is trapped with the balloon against the carotid
wall to identify the location of the fistula.
2 Neurosurg Focus / Volume 32 / May 2012
L. F. Gonzalez et al.
Fig. 3.  Left ICA microangiography with proximal occlusion showing
the fistulous point.
Results
Five patients with type A CCFs (4 women and 1 man),
with a mean age of 49 years (range 23–77 years) were
treated between August 2009 and September 2011 at our
institution (Table 1). All CCFs were successfully emboli-
zed using ethylene vinyl alcohol copolymer (Onyx 18) and
simultaneous balloon assistance. Two patients were treated
transarterially using the balloon as a buttress for coil em-
bolization. In one of these patients, the use of a balloon
allowed the identification of the fistulous site as well. The
other 3 patients were treated from the venous side with the
simultaneous assistance of an intraarterial balloon that al-
lowed the demarcation of the boundaries of the ICA and
prevented accidental reflux of the embolic material during
the course of embolization. The utility of balloon assis-
tance for all 5 patients is summarized in Table 1.
All fistulas were occluded at the end of the procedure.
Fig. 4.  Hyperglide balloon inflated in the left ICA while Onyx is in-
jected into the cavernous sinus through the inferior petrosal sinus route
(anteroposterior [left] and lateral [right] views). Note that the balloon
allows the visualization of the ICA when obscured by the embolic mate-
rial while also protecting the carotid artery from inadvertent Onyx em-
bolization.
Treatment of carotid-cavernous fistulas
Fig. 5.  Left ICA injection after a balloon is deflated for a control angi-
ography showing persistence of the fistula.
Preoperative and postoperative assessment of the intra-
ocular pressure (IOP) was obtained. The IOP decreased
immediately in all cases, and no rebound was seen. No
worsening of the cranial neuropathies was seen.
No complications were associated with the use of
a balloon. One patient with Ehler-Danlos syndrome de-
veloped a large retroperitoneal hematoma that required
urgent surgical evacuation with no neurological conse-
quence. Among the 5 treated patients, 4 underwent clini-
cal follow-up at a mean time point of 6.5 months (range
1–14 months) (Table 2). All 4 patients had reversal of their
nerve palsies at their respective follow-up visits. One pa-
tient had an available angiographic follow-up at 8 weeks
that confirmed occlusion of the CCF.
Discussion
Treatment of CCFs can be difficult. Different mo-
dalities have been described, including the transarterial
approach that is ideal for CCFs with a single arteriove-
nous connection.6,9 Detachable balloons have been used
to obliterate such fistulas but are currently not available
in the US. Coil embolization through a transarterial route
is a valuable treatment option for CCFs, especially in pa-
tients with large fistulous sites such as those that develop
following the rupture of carotid cavernous aneurysms.
This approach is, however, limited for CCFs with mul-
tiple arterial feeders given the difficulty and the risk of
catheterizing small arterial feeders.
The transvenous approach, popularized by Debrun et
al.,3 constitutes a versatile technique to access the cavern-
ous sinus through different possible routes including the
ipsilateral and contralateral IPSs, the facial and angular
veins, or the SOV via a surgical cut-down or direct punc-
TABLE 1: Summary of patient and fistula characteristics, treatment modality, and utility of balloon assistance*
Case Age (yrs), Type of
No. Sex Fistula Treatment Route
1 56, F A TA FS
2 24, F A TV IPS
3 77, F A TV IPS
4 64, M A TV IPS
5 23, F A TA FS
*  All fistulas were type A CCFs. Abbreviations: FS = fistula site; TA = transarterial; TV = transvenous.
Neurosurg Focus / Volume 32 / May 2012
Fig. 6.  Final angiography with a balloon deflated (anteroposterior
[left] and lateral [right] views) showing no arteriovenous shunting. Note
the multiple areas where the ICA is obscured by the embolic material.
LCCA = left common carotid artery.
ture.4 However, this approach is time consuming, and
the cost incurred by deploying large numbers of coils to
obliterate the fistula can be substantial. Additionally, coils
have the potential to compartmentalize in different areas
of the cavernous sinus, leaving untreated “pockets” in the
sinus and making it difficult for retreatment later on.4,5
Instead, deployment of a few coils, either transarterially
or transvenously, provides a framework for Onyx allow-
ing for safer and better embolization of the fistula.8 Once
access is obtained, the cavernous sinus can be embolized
with coils in a distal-to-proximal fashion, starting usually
at the SOV and packing the sinus progressively.
Arat et al.1 described for the first time the use of
Onyx in the treatment of CCFs. In contrast to other liq-
uid embolic agents, Onyx is nonadhesive and has unique
solidification characteristics that allow precise delivery at
the desired location and pace. Onyx also offers the advan-
tage of filling all the intrinsic interstices of the cavernous
sinus, making it an ideal agent for embolizing CCFs.
The concomitant use of a balloon has been described
during treatment of dural arteriovenous fistulas.7 When
embolization is performed through a transarterial route, a
balloon can be inflated in the venous circulation to protect
a sinus in close proximity to the fistulous site.7 Balloon as-
sistance during embolization of CCFs was used by Zente-
no et al.10 and Elhammady et al.5 to increase microcatheter
Balloon Etiology Agent Purpose
Hyperglide posttraumatic Onyx 18 visualization, buttress, localization &
 protection
Hyperglide posttraumatic Onyx & coils buttress
Hyperglide spontaneous Onyx & coils visualization
Hyperglide spontaneous Onyx & coils visualization
Hyperglide spontaneous Onyx & coils visualization, buttress
3

TABLE 2: Etiology, presentation, and outcome of treated
patients*
Follow-Up Clinical
Case No. Etiology Presentation (mos) Outcome
1 posttraumatic CN VI, bruit 5 CR
2 posttraumatic HA, CN VI 6 CR
3 spontaneous HA, CN VI NA NA
4 spontaneous CN VI 1 CR
5 spontaneous CN VI, bruit 14 CR
*  CN VI = cranial nerve VI; CR = complete resolution; HA = headache;
NA = not available.
purchase and avoid reflux of the embolic material into the
arterial circulation. However, these authors did not use the
balloon for identification of the fistulous site or demarca-
tion of the ICA during embolization. The latter indication
is a potentially key feature of balloon assistance, especially
when liquid agents are used to obliterate the fistula. We
routinely use the assistance of a conformal, highly compli-
ant balloon such as the Hyperglide (ev3, Inc.) with the pur-
pose of buttressing coils deployed in the cavernous sinus
through the rent in the carotid artery wall. Additionally,
when using Onyx through a transvenous route, a balloon
can protect the ICA from inadvertent embolization into the
intracranial circulation.5 We prefer an elongated conformal
balloon (Hyperglide) rather than the highly conformal but
shorter balloon (Hyperform, Inc.) that was used by Elham-
mady et al.5 In fact, the Hyperglide balloon covers a longer
segment, which allows better identification of the carotid
artery during the course of embolization.
Having a balloon inflated in the ICA with a trapped
microcatheter can help localize the fistulous site, especially
when high-flow lesions are approached transarterially. As
Onyx injection progresses, it becomes difficult to visualize
the boundaries of the carotid artery due to the progressive
“encasement” within the Onyx cast. Having the balloon
inflated will delimit the boundaries of the ICA while si-
multaneously preventing accidental Onyx reflux. Two min-
utes after the injection, the balloon is deflated, and distal
branches are checked to rule out embolic accidents. Usual-
ly, heparin is avoided during embolization of arteriovenous
fistulas or malformations to facilitate clotting. However,
we routinely use heparin, targeting an active clotting time
around 2.5 times the baseline to prevent thromboembolic
events.
Having a balloon in the ICA may add another layer
of complexity to these cases and introduces the potential
for thromboembolic events. However, we believe that bal-
loon assistance has an excellent safety-efficacy profile and
should be given strong consideration in the treatment of
CCFs.
Conclusions
Balloon-assisted treatment of CCFs is a useful tech-
nique to prevent inadvertent migration of the embolic
material within the arterial compartment. Additionally,
it facilitates the visualization of the fistulous point and
demarcates the ICA.
4 Neurosurg Focus / Volume 32 / May 2012
L. F. Gonzalez et al.
Although no complications were noted with balloon
assistance in this small series, the technique theoretically
may increase the risk of thromboembolic phenomenon.
Anticoagulation is mandatory when the balloon is inflat-
ed. More disseminated use of this technique will be nec-
essary to establish its safety and efficacy. Balloon-assisted
treatment of CCFs with Onyx appears to hold tremendous
promise as a rapid and safe strategy for complete oblitera-
tion of these often challenging lesions.
Disclosure
Dr. Tjoumakaris is a consultant for Stryker, and Dr. Dumont is
a consultant for ev3, Inc.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Gonzalez. Acquisi-
tion of data: Gonzalez, Chalouhi. Analysis and interpretation of
data: Gonzalez, Chalouhi, Tjoumakaris. Drafting the article: all
authors. Critically revising the article: all authors. Reviewed submit-
ted version of manuscript: all authors. Approved the final version of
the manuscript on behalf of all authors: Gonzalez. Administrative/
technical/material support: Gonzalez, Chalouhi. Study supervision:
Gonzalez.
References
  1.  Arat A, Cekirge S, Saatci I, Ozgen B: Transvenous injection of
Onyx for casting of the cavernous sinus for the treatment of a
carotid-cavernous fistula. Neuroradiology 46:1012–1015, 2004
  2.  Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC,
Tindall GT: Classification and treatment of spontaneous carot-
id-cavernous sinus fistulas. J Neurosurg 62:248–256, 1985
  3.  Debrun G, Lacour P, Vinuela F, Fox A, Drake CG, Caron JP:
Treatment of 54 traumatic carotid-cavernous fistulas. J Neu-
rosurg 55:678–692, 1981
  4.  Elhammady MS, Peterson EC, Aziz-Sultan MA: Onyx embo-
lization of a carotid cavernous fistula via direct transorbital
puncture. Case report. J Neurosurg 114:129–132, 2011
  5.  Elhammady MS, Wolfe SQ, Farhat H, Moftakhar R, Aziz-
Sultan MA: Onyx embolization of carotid-cavernous fistulas.
Clinical article. J Neurosurg 112:589–594, 2010
  6.  Gemmete JJ, Ansari SA, Gandhi DM: Endovascular tech-
niques for treatment of carotid-cavernous fistula. J Neuro­
ophthalmol 29:62–71, 2009
  7.  Shi ZS, Loh Y, Duckwiler GR, Jahan R, Viñuela F: Balloon-
assisted transarterial embolization of intracranial dural ar-
teriovenous fistulas. Clinical article. J Neurosurg 110:921–
928, 2009
  8.  Spiotta AM, Hughes G, Masaryk TJ, Hui FK: Balloon-aug-
mented Onyx embolization of a dural arteriovenous fistula
arising from the neuromeningeal trunk of the ascending pha-
ryngeal artery: technical report. J Neurointerv Surg 3:300–
303, 2011
  9.  Tjoumakaris SI, Jabbour PM, Rosenwasser RH: Neuroendo-
vascular management of carotid cavernous fistulae. Neuro-
surg Clin N Am 20:447–452, 2009
10.  Zenteno M, Santos-Franco J, Rodríguez-Parra V, Balderrama
J, Aburto-Murrieta Y, Vega-Montesinos S, et al: Management
of direct carotid-cavernous sinus fistulas with the use of eth-
ylene-vinyl alcohol (Onyx) only: preliminary results. Clinical
article. J Neurosurg 112:595–602, 2010
Manuscript submitted January 10, 2012.
Accepted February 6, 2012.
Please include this information when citing this paper: DOI:
10.3171/2012.2.FOCUS1213.
Address correspondence to: L. Fernando Gonzalez, M.D., Depart-
ment of Neurological Surgery, Division of Neurovascular Surgery
and Endovascular Neurosurgery, Thomas Jefferson University
Hospital, 909 Walnut Street, 2nd Floor, Philadelphia, Pennsylvania
19107. email: fernando.gonzalez@jefferson.edu.