Unusual Case of Recurrent Carotid-Cavernous Fistula after 47 Years, Treated with Direct Clip Ligation of the Petrous Internal Carotid Artery

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.