Introduction: Carotid-cavernous fistulas (CCFs) are arteriovenous fistulas (AVFs) between the carotid
artery or its branches and the adjacent cavernous sinus. The purpose of this report
is to present a case of recurrent indirect CCF presenting 47 years after previous
operative trapping of the ICA for traumatic direct CCF, the longest reported recurrence
to date.
Methods: A spontaneous recurrence of indirect carotid-cavernous fistula presented 47 years
following initial surgical trapping of the internal carotid artery for traumatic direct
carotid-cavernous fistula.
Results: The patient was successfully treated with an orbitozygomatic extended middle cranial
fossa approach for direct petrous internal carotid artery clip ligation after failure
of percutaneous embolization techniques.
Conclusions: CCFs can be difficult entities to treat, requiring extensive knowledge and experience
with both potential endovascular and surgical options. In addition, recurrences are
not uncommon and may present remotely from initial treatment and with different anatomical
configurations. This also represents, to our knowledge, the first case reported that
required direct petrous carotid ligation to treat the fistula after all endovascular
and standard approaches were attempted or not plausible. Clinicians must be aware
of these possibilities and ensure close follow-up to guarantee long-term occlusion.
