Clinical efficacy of endovascular treatment approach in patients with carotid cavernous fistula: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Carotid-cavernous fistulas (CCFs) represent a group of rare, abnormal arteriovenous communications between the carotid arterial system and the cavernous sinuses (CS). CCFs often produce ophthalmologic symptoms related to increased CS pressures and retrograde venous drainage of the eye. Although endovascular occlusion remains the preferred treatment for symptomatic or high-risk CCFs, most of the data for these lesions is limited to small, single-center series. As such, we performed a systematic review and meta-analysis evaluating endovascular occlusions of CCFs to determine any differences in clinical outcomes based on presentation, fistula type, and treatment paradigm.

METHOD: A retrospective review of all studies discussing the endovascular treatment of CCFs published through March 2023 was conducted using PubMed, Scopus, Web of Science, and Embase databases. A total of 36 studies were included in the meta-analysis. Data from the selected articles were extracted and analyzed using Stata software version 14.

RESULTS: 1494 patients were included. 55.08% were female and the mean age of the cohort was 48.10 years. A total number of 1516 fistulas underwent endovascular treatment, 48.05% of which were direct and 51.95% of which were indirect. 87.17% of CCFs were secondary to a known trauma while 10.18% were spontaneous. The most common presenting symptoms were 89% exophthalmos (95% CI: 78.0-100.0; I2  = 75.7%), 84% chemosis (95% CI: 79.0-88.0; I2  = 91.6%), 79% proptosis (95% CI: 72.0-86.0; I2  = 91.8%), 75.0% bruits (95% CI: 67.0-82.0; I2  = 90.7%), 56% diplopia (95% CI: 42.0-71.0; I2  = 92.3%), 49% cranial nerve palsy (95% CI: 32.0-66.0; I2  = 95.1%), 39% visual decline (95% CI: 32.0-45.0; I2  = 71.4%), 32% tinnitus (95% CI: 6.0-58.0; I2  = 96.7%), 29% elevated intraocular pain (95% CI: 22.0-36.0; I2  = 0.0%), 31% orbital or pre-orbital pain (95% CI: 14.0-48.0; I2  = 89.9%) and 24% headache (95% CI: 13.0-34.0; I2  = 74.98%). Coils, balloons, and stents were the three most used embolization methods respectively. Immediate complete occlusion of the fistula was seen in 68% of cases and complete remission was seen in 82%. Recurrence of CCF occurred in only 35% of the patients. Cranial nerve paralysis after treatment was observed in 7% of the cases.

CONCLUSIONS: Exophthalmos, Chemosis, proptosis, bruits, cranial nerve palsy, diplopia, orbital and periorbital pain, tinnitus, elevated intraocular pressure, visual decline and headache are the most common clinical manifestations of CCFs. The majority of endovascular treatments involved coiling, balloons and onyx and a high percentage of CCF patients experienced complete remission with the improvement of their clinical symptoms.