From 1974 to 1986, 148 patients with carotid cavernous fistula (CCF) were evaluated for intravascular therapy. Four patients died from hemorrhage before treatment could be instituted and the CCF closed spontaneously in 5. Therapeutic approaches which resulted in complete occlusion in the remaining 139 cases were transarterial in 118, transvenous in 15 and external compression of the carotid artery and jugular vein in 6. The current treatment of choice of the direct CCF is intravascular embolization using detachable balloons, particulate emboli or liquid adhesive agents to occlude the CCF while attempting to preserve the carotid artery. In 15 patients it was technically too difficult to use the transarterial approach. The patients were therefore treated from a transvenous approach including access via the femoral vein, superior ophthalmic vein, intraoperatively from the inferior petrosal sinus or direct puncture of the cavernous sinus. Embolic agents used included detachable silicone balloons, steel minicoils, particulate emboli and isobutyl-2-cyanoacrylate. In 14 of these 15 patients total obliteration was achieved with marked improvement in symptoms. Complications occurred in 3 patients including perforation of the cavernous sinus resulting in subarachnoid hemorrhage, delayed pontine hemorrhage from subtotal occlusion of the fistula and transient increased proptosis.