Abstract
BackgroundThe development of carotid-cavernous fistulas (CCFs) during surgical recanalization of chronic internal carotid artery occlusion (ICAO) may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic CCFs. The purpose of this study is to investigate the causal relationship between the CCFs and severe ICA dissections and to characterize technical outcomes after treatment with stenting.MethodsFive patients underwent treatment with self-expanding stents due to intraprocedural CCF and ICA dissection following surgical removal of ICAO plaque. The stents were telescopically placed via true channel of the dissection. Safety of the procedure was evaluated with 30-day stroke and death rate. Procedural success was determined by the efficacy of CCF obliteration and ICAO recanalization with angiography.ResultsAll CCFs were associated with spiral and long segmental dissection from the cervical to cavernous ICA. After stenting, successful dissection reconstruction with TICI 3 was achieved in all patients, with complete (n = 4) or partial CCF (n = 1) obliteration. No patient had CCF syndrome, stroke, or death during follow-up of 6 to 37 months; but one patient had pulsatile tinnitus, which resolved 1 year later. Angiography at 6 to 24 months demonstrated CCF obliteration in all 5 patients and durable ICA patency in 4 patients.ConclusionsIntraprocedural CCFs with spiral and cervical-to-cavernous ICA dissection during ICAO surgery are dissection-related because of successful obliteration after stenting for dissection reconstruction. Self-expanding stenting through true channel of the dissection, serving as implanting stent-autograft, may be an optimal therapy for the atypical CCF complication from ICAO surgery.
Highlights
The development of carotid-cavernous fistulas (CCFs) during surgical recanalization of chronic internal carotid artery occlusion (ICAO) may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic Carotid-cavernous fistula (CCF)
The CCFs are observed on angiography after immediate open surgical removal of the ICAO plaque and are likely associated with severe dissection from the cervical to cavernous ICA, rather than a focal tear at the cavernous ICA seen in typical traumatic CCFs
Indications and contraindications of hybrid surgery Indications for hybrid surgery of symptomatic chronic ICAO were transient ischemic attack (TIA) or ischemic stroke within 3 months; total ICAO related to the cerebral ischemic event and documented by ultrasound, CT angiography (CTA), magnetic resonance angiography, or catheter angiography at least 2 weeks before the revascularization procedure; patency of the ipsilateral middle cerebral artery (MCA) via the Willis collaterals, or the ipsilateral ophthalmic artery or other external carotid-ICA collaterals; ipsilateral cerebral hypoperfusion revealed by CT or MR perfusion imaging; infarct size less than one third of the ipsilateral MCA territory on MR/CT images; and preprocedural treatment with aspirin 300 mg and clopidogrel 75 mg daily for at least 5 days
Summary
The development of carotid-cavernous fistulas (CCFs) during surgical recanalization of chronic internal carotid artery occlusion (ICAO) may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic CCFs. The purpose of this study is to investigate the causal relationship between the CCFs and severe ICA dissections and to characterize technical outcomes after treatment with stenting. CCFs can develop as a complication of surgical recanalization of symptomatic chronic internal carotid artery occlusions (ICAOs) [11, 12] In these cases, the CCFs are observed on angiography after immediate open surgical removal of the ICAO plaque and are likely associated with severe dissection from the cervical to cavernous ICA, rather than a focal tear at the cavernous ICA seen in typical traumatic CCFs. The findings suggest that the severe ICA dissection likely harbors a false lumen with intimal entry at the proximal ICA and adventitial exit at the cavernous ICA. Our aim is to investigate the causal relationship between the ICA dissections and CCFs during hybrid ICAO surgery and to characterize technical outcomes after treatment with stenting
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