Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 812-817
World Neurosurgery

Technical Note
Flow Diverters as Useful Adjunct to Traditional Endovascular Techniques in Treatment of Direct Carotid-Cavernous Fistulas

https://doi.org/10.1016/j.wneu.2017.06.113Get rights and content

Background

Direct carotid-cavernous sinus fistulas (CCFs) are high-flow arteriovenous shunts that are typically the result of a severe head injury. The endovascular treatment of these lesions includes the use of detachable balloons, coils, liquid embolic agents, and covered stents. To minimize the chance of treatment failure and subsequent complications, endoluminal reconstruction using a flow-diverting stent may be added to the treatment construct.

Methods

We present 3 cases and review the existing literature.

Results

Three patients with direct traumatic CCFs were treated with either coils, coils and Onyx, or a detachable balloon, followed by placement of a flow-diverting stent for endoluminal reconstruction. All 3 cases had complete angiographic occlusion of the CCFs and recovered clinically. No complications were observed.

Conclusions

We believe that endovascular coil or balloon occlusion of the fistula from either a transvenous or transarterial approach followed by flow diversion may be an appropriate treatment for direct CCFs. This addition of a flow diverter may facilitate endothelialization of the injury to the internal carotid artery.

Introduction

Direct carotid-cavernous sinus fistulas (CCFs) are high-flow arteriovenous shunts that are typically the result of a severe blunt or penetrating head injury or, less frequently, a ruptured intracavernous aneurysm.1 The treatment of these lesions has evolved dramatically over the past few years with improved endovascular devices and techniques. Transvenous and transarterial access has been described with use of detachable balloons,2, 3 coils,2, 3 liquid embolic agents,3, 4, 5 and covered stents.6, 7 Detachable balloons were commonly used to treat high-flow CCFs, until they were withdrawn in the United States.8

More recently, coils have become the mainstay of treatment for high-flow CCFs. Typically, a transarterial or transvenous route is used to reach the site of the fistula in the cavernous sinus (CS), which is filled with coils to eliminate the shunt between internal carotid artery (ICA) and the CS.2 Detachable balloons can also be used for the same purpose. However, treatment failures have been known to occur and recanalization of the fistula and intracranial hemorrhage have been described.1, 4 In order to minimize the chance of treatment failure and subsequent complications, endoluminal reconstruction can be added to the treatment construct by placement of a flow-diverting device in the ICA as an adjunct to coil or balloon placement in the CS.1, 9, 10, 11, 12, 13, 14 Here, we describe 3 patients treated at 2 centers in the United States and Middle East using this technique and a review of the existing literature.

Section snippets

Materials and Methods

Adjunctive direct CCF treatment using a flow-diverter was performed according to the standards previously described.1, 15 In all 3 patients, a loading dose of 600 mg clopidogrel and 650 mg aspirin was prescribed and a 50–60 IU/kg body weight bolus of heparin was administered during the procedure. All procedures were performed under general anesthesia. Patients were discharged home on clopidogrel 75 mg daily and aspirin 325 mg daily for at least 3 months. Patient characteristics are presented in

Case 1

Pretreatment angiography confirmed a left direct CCF (Figure 1A). A 6-Fr sheath was placed into the right common femoral artery and a 6-Fr guide catheter in the left ICA (Benchmark, Penumbra, Alameda, California, USA). Next, a Berenstein 2 diagnostic catheter (Cordis, California, USA) was navigated into the left ICA and the ICA was occluded by inflation of a Sterling monorail balloon (Boston Scientific, Marlborough, Massachusetts, USA). Balloon test occlusion was meant as a back-up if the

Discussion

There has been an evolution in the treatment of direct CCFs. Initial endovascular techniques involved carotid artery sacrifice with detachable balloons.17 Later, refinements in the endovascular armamentarium allowed for microcatheter transgression of the fistula with deployment of detachable balloons at the fistulous connection, typically through a transarterial approach.18 Ultimately, detachable balloons were removed from use in the United States but remain available in other countries. In a

Conclusion

Our experience and literature review presented suggests that endovascular coil or balloon occlusion of the fistula from either a transvenous or transarterial approach followed by flow diversion may be a suitable treatment for direct CCFs. This addition of a flow diverter may facilitate endothelialization of the injury in the internal carotid artery.

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