Recurrent carotico-cavernous fistula after internal carotid artery ligation: a case with embolization of the fistula via contralateral internal carotid artery approach.

We are reporting a 51-year-old female patient having a history of direct carotid cavernous fistula (CCF) which was treated by internal carotid artery (ICA) ligation 17 year ago. She presented to Ho Chi Minh City University Medical Center with symptoms of recurrent CCF. The recurred CCF was supplied by multiple feeders coming from anterior, posterior communicating artery and the recanalized left ICA. Her CCF was not plausible for another surgical ligation and was referred for endovascular treatment. The fistula was eventually occluded by percutaneous embolization via the right ICA approach. Through this case, we would like to discuss about the treatment strategies of those having recurrent CCF with preexisted ICA ligation. In Vietnam, previously carotico-cavernous fistula was mainly treated with muscle occlusion, carotid artery ligation or combinations of these methods. There were reported good outcomes for treatment of CCF surgically. However, surgical repairs had carried, not only complication, but a risk of recurrence due to recanalization of the previously ligated ICA. Since the emergence of endovascular intervention, the treatment of direct CCF has evolved from surgical ligation to angiographic embolization using balloon or coils via artery route or venous access. This endovascular method currently is the treatment of choice for traumatic CCF due to its ability to preserve the carotid artery and flexibility in treatment strategy with various approaches to the fistula.