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We report the case of a woman with bilateral carotid artery fibromuscular dysplasia. The case illustrates some of the difficulties encountered in the treatment of carotid-cavernous fistula. For example, a previous contralateral carotid closure caused complications because carotid sacrifice was not now possible. This resulted in several embolization procedures requiring prolonged x-ray exposures. We show that transvascular embolotherapy must incorporate a flexible approach for access, selection of embolic materials, and clinical care.