Successful treatment of six cases of indirect carotid-cavernous fistula with ethylene vinyl alcohol copolymer (Onyx) transvenous embolization

J Neuroophthalmol. 2009 Mar;29(1):3-8. doi: 10.1097/WNO.0b013e318199c85c.


Background: Endovascular transvenous treatments have become the mainstay in the management of indirect carotid-cavernous fistulas (CCFs). However, the standard coil techniques are associated with a substantial failure and complication rate. The ethylene vinyl alcohol copolymer (Onyx) Liquid Embolization System has advantages over coils, including the ability to penetrate and occlude vessels of small caliber or with difficult access.

Methods: This was a review of 5 consecutive patients with indirect type D CCFs who underwent 6 procedures using the Onyx system alone at the Prince of Wales Hospital, Sydney, between December 2005 and May 2007. The cavernous sinus was catheterized with MTI Echelon-10 or Rebar-14 microcatheters via the femoral vein using an inferior petrosal approach to the cavernous sinus in 5 procedures and directly via the superior ophthalmic vein in 1 procedure.

Results: All 5 patients had complete closure of the fistulas as seen on imaging and full reversal of ophthalmic manifestations without lingering complications and with substantially shorter procedure times than with conventional approaches.

Conclusions: The Onyx system is a safe and useful method of closing indirect CCFs transvenously. This is the first series report of the use of the Onyx system alone in the treatment of these vascular abnormalities.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Angiography
  • Angiography, Digital Subtraction
  • Carotid Artery, Internal / diagnostic imaging
  • Carotid-Cavernous Sinus Fistula / diagnostic imaging
  • Carotid-Cavernous Sinus Fistula / therapy*
  • Dimethyl Sulfoxide / therapeutic use*
  • Embolization, Therapeutic / methods*
  • Female
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Polyvinyls / therapeutic use*


  • Onyx copolymer
  • Polyvinyls
  • Dimethyl Sulfoxide