SELECTION OF ENDOVASCULAR ACCESS ROUTE IN DURAL CAROTID-CAVERNOUS FISTULAS: CONTEMPORARY EVIDENCE AND AN ANATOMY-BASED CLINICAL ALGORITHM

Background. Dural carotid-cavernous fistula (dCCF) is a pathological arteriovenous shunt between the meningeal branches of the internal or external carotid artery and the cavernous sinus. It may lead to orbital venous hypertension, visual decline, cranial nerve dysfunction, and severe neurological and ophthalmological complications when cortical venous reflux is present. Endovascular embolization is the primary treatment for symptomatic or high-risk dCCFs, but the choice of access route depends on more than the Barrow classification alone.

Aim. To analyze endovascular access routes in dCCF based on contemporary literature, to outline the anatomical and clinical factors influencing route selection, and to propose a practical decision algorithm based on venous drainage characteristics.

Materials and methods. Systematic reviews and multi- and single-center retrospective series published between 2015 and 2026 were analyzed; findings were grouped by access route, venous anatomy, and clinical risk criteria.

Results. Transvenous embolization via the inferior petrosal sinus (IPS) remains the first-line approach in most patients (complete occlusion — 88.1%). When IPS access is not feasible, transorbital access via the superior ophthalmic vein (SOV) (surgical cutdown — 90.0%; direct puncture — 97.4%) and the transfacial venous route serve as practical alternatives. Transarterial embolization (75.6%) is mainly used for fistulas with predominant external carotid artery branches (Barrow type C/D).

Conclusion. Selection of the endovascular access route should depend less on fistula type and more on venous drainage anatomy, cortical venous reflux, and visual/neurological risk. The transvenous IPS route remains the primary choice, while transorbital, transfacial, and transarterial methods represent anatomy-based, staged alternatives.