<p>Cavernous sinus dural arteriovenous fistula (CS-DAVF) is a rare vascular disorder, with clinical manifestations largely determined by venous drainage patterns. Conventional endovascular treatment via the inferior petrosal sinus or superior ophthalmic vein may be unsuccessful when these access routes are occluded. We report a case of an CS-DAVF (Barrow type D) in which two prior endovascular attempts failed, and complete obliteration of the fistula was subsequently achieved through direct puncture of the cavernous sinus under endoscopic endonasal guidance. Postoperatively, the patient experienced complete resolution of pulsatile tinnitus and stabilization of ocular function. This case suggests that the endoscopic endonasal approach may represent a safe and effective alternative for carefully selected indirect CS-DAVF patients when standard endovascular access is not feasible.</p>