Long-Term Recovery Trajectories After Endovascular Treatment of Carotid-Cavernous Fistulas: A Single-Center Cohort Study

Abstract

BACKGROUND AND OBJECTIVES: Carotid-cavernous fistulas (CCFs) are uncommon arteriovenous shunts that can present with a wide range of nonspecific ophthalmic and neurological symptoms, often leading to diagnostic delays. While endovascular embolization is the primary treatment modality, data on long-term functional outcomes and the prognostic value of baseline symptom burden remain limited. METHODS: We conducted a retrospective single-center cohort study of consecutive patients with angiographically confirmed CCFs treated with endovascular embolization between 2009 and 2025. Clinical outcomes were assessed at early follow-up (median 1.5 months) and long-term follow-up (>1 year; median 52 months). Logistic regression analyses were used to evaluate the association between symptom burden, angiographic occlusion status, and failure of clinical improvement. RESULTS: A total of 107 patients were included (median age: 64 years, 35% male). Diagnostic delays were common (median duration from symptom onset to treatment: 30 days), frequently due to misdiagnosis as inflammatory, infectious, or vascular orbital conditions. Early follow-up demonstrated complete or partial improvement in 91% of patients, with significant progression from partial to complete improvement at long-term follow-up ( P = .001). Complication and repeat treatment rates were low. Neither symptom duration nor number of presenting symptoms was associated with failure of improvement at early or long-term follow-up ( P ≥ .05). Complete angiographic obliteration at the end of the procedure was associated with improved early outcomes (odds ratio 0.09; 95% CI, 0.02-0.39), while complete occlusion at last radiological follow-up predicted favorable long-term outcomes (odds ratio 0.15; 95% CI, 0.02-0.94). CONCLUSION: Endovascular embolization of CCFs is associated with excellent clinical outcomes and sustained long-term improvement. Symptom burden and diagnostic delays did not predict post-treatment recovery, whereas durable angiographic occlusion was a key determinant of outcome. These findings support intervention even in patients presenting late and emphasize the importance of achieving complete fistula occlusion.