Surgical Treatment of Carotid-Cavernous Fistulas

Abstract

Carotid–cavernous fistulas are rather frequent and take a typical clinical course. Their incidence rate takes the second place, after the arterial aneurysms of the brain. Functionally, a carotid–cavernous fistula is an arterio–venous aneurysm, while from a structural–anatomical point of view a fistula and an aneurysm are completely different pathological forms. This fact determines the following most important postulation: in cases of fistulas, in contrast to arterio–venous aneurysms, it is impossible to restore the separate arterial and venous circulation, since surgical intervention is impossible within the fistula itself. This, in its turn, puts forward the operative task of the distant occlusion of the efferent arteries, or of an intravascular closure of the defect in the carotid artery. Intracranial clipping of the carotid artery was performed in 27 of the 69 operated patients. The next 60 patients were operated by means of simultaneous intracranial occlusion of the carotid artery with tamponage of the cavernous part of the carotid artery with a piece of muscle marked with a silver clip and ligation of the internal carotid artery in the neck. This operation permits avoiding all cerebral complications and prevents blood supply to the fistula, thus providing full success of the operation. In all these cases the muscular embolus was transported to the fistula hydraulically through the plastic tube inserted into the internal carotid artery. This operation can be performed with the help of any plastic material, but in our opinion, muscle is the best one. The original Brooks operation has one important drawback: the muscular embolus is not controlled and may embolize the middle cerebral artery.