Intrafistula pressure measurement in traumatic carotid cavernous fistulas--key to increasing safety and effectiveness of endovascular coiling.

Abstract

Very few diseases demostrate the tremendous variation and capricious results common with the clinical ensemble of carotid cavernous fistulas (CCFs). The treatment modality for CCFs has changed from surgical to endovascular therapy. Many options exist in endovascular therapy ranging from balloons to coils and liquid embolization agents like Onyx. This study was undertaken to assess the role of recording intra-fistula pressure (IFP) during endovascular coiling of CCFs in order to help us better understand the angiodynamics of the fistula and to make coiling safer and effective. IFP measurement was done in 15 cases of traumatic CCF undergoing endovascular coiling. Patients were prospectively analyzed by pre- and post- procedural clinical profile, degree of recovery and time until fistula occlusion. Univariate analysis was used to find the correlation between the reduction in IFP, the degree of fistula obliteration and time until occlusion. Of the 15 patients who underwent endovascular coiling 13 had total occlusion of the fistula, 1 patient had subtotal occlusion and 1 patient had no occlusion of the fistula. There was 100 % internal carotid artery (ICA) patency. Univariate analysis showed a strong correlation between the degree of reduction in IFP and time required for fistula occlusion (p < 0.001). Patients with a significant drop in IFP were also preceived as having a higher chance of fistula occlusion after waiting 30 min. To our knowledge this is the largest series in published literature focused on using only detachable coils as the first line embolizing agent in treatment of traumatic CCFs. We conclude that IFP monitoring will play an important role in making treatment of CCFs safer and more effective. The aim of coiling the fistula is not to tightly pack the fistula as during treatment of aneurysms; rather it is to reduce flow across the fistula leading to thrombosis thus reducing the requirement of coils.