Case Of Carotid-cavernous Fistula Research Articles

Neglected Superior Ophthalmic Vein Enlargement Before Delayed Symptom of Carotid-Cavernous Fistula in a Blow-Out Fracture: A Case Report and Literature Review

Carotid-cavernous fistula (CCF) is rare condition. However, it should be suspected when there are traumatic facial fractures, because if not diagnosed, it can lead to permanent damage such as blindness. Traumatic CCF often presents delayed symptoms, and delayed diagnosis without prompt treatment can lead to permanent injuries in optic and cranial nerves III, IV, V, and VI as well as intracranial hemorrhage. The routine initial modality for patients with suspected facial bone fractures is non-contrast computed tomography (CT) to identify any fracture lines and check for intracranial hemorrhage. We report a post-traumatic CCF case with a 4-day symptom delay, where left superior ophthalmic vein enlargement was observed on the routine non-contrast facial CT with ipsilateral orbital wall fracture. When the patient first presented to the emergency room, we did not detect vein enlargement on CT. Afterwards, the patient developed delayed symptoms of CCF and was re-admitted to the emergency room. When we re-analyzed the first CT scan, an enlarged superior ophthalmic vein was confirmed. The diagnosis was confirmed via magnetic resonance imaging angiography, and the patient was successfully treated with embolization of the fistula. Thus, we recommend reviewing ophthalmic vein enlargement that is readily identifiable through non-contrast CT for patients injured by craniofacial trauma to suspect the presence of delayed CCF at their initial presentation.

Abstract 162: Indirect Carotid Cavernous Fistula with Oculomotor Nerve Palsy Secondary to Trauma

Introduction Intriguing and uncommon, we present a fascinating case of carotid‐cavernous fistula (CCF) following ocular trauma. Delving into medical nuances and outcomes, this reported case offers valuable insights for clinicians and researchers in the field of ophthalmology and interventional Neurology. Methods An elderly patient presented to the emergency department with diplopia and left eyelid ptosis two weeks after left ocular trauma. The patient had exotropia and hypotropia with restricted movement in all directions but mostly during adduction and infraduction which led to the diagnosis of oculomotor nerve palsy. Computer Tomography (CT) head was obtained which showed mild left proptosis with the prominence of the optic nerve sheath complex, CT angiography revealed asymmetric prominence of the left ophthalmic veins and enlarged left cavernous sinus with outward convex borders. CT face and mandible with IV contrast did not show any bony deformity. The patient underwent cerebral angiography that showed an indirect type 4 cavernous‐carotid fistula. Results A precise incidence of CCF fistula has not been reported so far in the literature but it is estimated to be present in 0.2 % of patients presenting with traumatic brain injury with an increased incidence of 4 % with basilar skull fractures. They can occur spontaneously or following closed skull injury, skull base fractures, or iatrogenically after craniotomies, endoscopic transsphenoidal or sinus surgery, and endovascular procedures. They can be classified based on angiographic arterial architecture (direct or indirect), hemodynamics (high flow or low flow), and etiology (spontaneous or traumatic). Type A are direct fistulas, whereas types B, C, and D are indirect fistulas. Direct CCFs often present with pulsatile exophthalmos, orbital bruit, chemosis, diplopia, ocular redness, orbital pain, swelling, swishing or buzzing sounds, headache, or vision loss. Indirect low‐flow CCFs may be asymptomatic and insidious in onset and mostly present with chemosis and conjunctival injection. Conclusion Indirect carotid‐cavernous fistula rarely occurs secondary to a head trauma without any bony deformity and it's even rare to have an oculomotor nerve palsy on presentation, it should be considered as an etiology when evaluating patients for ocular nerve palsies.

Abstract Number ‐ 80: Embolization of Carotid Cavernous Fistula Through Occluded Inferior Petrosal Sinus Access

Introduction Carotid cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus. The most common presenting symptoms are proptosis, chemosis, orbital bruit and headache. Visual disturbances such as diplopia, ophthalmoplegia and cranial nerve deficits can also occur. Pulsatile tinnitus is an unusual finding which necessitates further workup in this population. Endovascular obliteration with transvenous embolization for indirect fistulas is the preferred approach for CCF closure. Navigation is achieved through the inferior petrosal sinus or facial and superior ophthalmic vein. Here, we describe a case of carotid cavernous fistula that was successfully treated through occluded right inferior petrosal sinus access using coil and Onyx embolic material. Methods A 56‐year‐old‐male with no past medical history presented with right eye proptosis and pulsatile tinnitus. His eye symptoms progressively worsened with decrease in visual acuity, gaze restriction and exophthalmos which correlated with the resolution of pulsatile tinnitus. MRI demonstrated significant inflammation involving the right orbit and atypical enhancement of basal frontal lobe adjacent to orbit. MRA suggested early opacification of the right superior ophthalmic vein and subtle flow voids in posterior lateral aspect of right cavernous sinus. Further evaluation with cerebral angiogram revealed a Barrow Type D right carotid cavernous fistula supplied by meningo‐hypophyseal branches of bilateral internal carotid arteries and right internal maxillary branch. It demonstrated high flow retrograde shunting in right superior ophthalmic vein and a basal frontal isolated cortical vein. There was near complete occlusion of the right sigmoid sinus and inferior petrosal sinus due to significant thrombus burden as well as stenosis of the right internal jugular vein. Results Patient underwent embolization of right carotid cavernous fistula with transvenous approach. A microcatheter was advanced to the origin of the intercavernous sinus but was not able to cross due to exceptionally small channels connecting both cavernous sinuses. The right internal jugular vein was subsequently identified and injection demonstrated occlusion of right sigmoid sinus due to near complete occlusive thrombus in addition to occlusion of the major channels of the inferior petrosal sinus. The microcatheter was blindly advanced into the inferior petrosal sinus maintaining the symmetry from contralateral inferior petrosal sinus trajectory. We were able to reach the fistulous point in the posterior medial aspect of the right cavernous sinus using an Echelon 1045 microcatheter. Coils were subsequently deployed and fistula was noted to be occluded. Onyx was injected through the microcatheter to avoid recanalization of fistula. A follow‐up left internal carotid artery and right common carotid artery injections confirmed angiographic cure of the fistula. Conclusions Carotid cavernous fistula is a rare but treatable cause of rapidly progressive vision loss with pulsatile tinnitus as an unusual finding. We present a case of challenging access and successful treatment with transvenous approach through near complete occlusion of the inferior petrosal sinus.

Carotid cavernous fistula presenting as orbital cellulitis

Carotid cavernous fistula is a serious vascular pathology that is commonly misdiagnosed due to clinical signs that overlap with several other pathologies and the need for sensitive imaging techniques, most notably digital subtraction angiography, to make the diagnosis. Here we present a case of carotid cavernous fistula mimicking orbital cellulitis, ultimately diagnosed with magnetic resonance venography.

O058 Characteristics and prognosis of cerebrovascular fibromuscular dysplasia (FMD) - a retrospective cohort study

Abstract Introduction Fibromuscular dysplasia (FMD) is a rare, non-atherosclerotic, non-inflammatory vascular disorder that primarily affects renal and cerebrovascular vessels. Limited data are available on the clinical characteristics of cerebrovascular FMD, particularly from the UK/Europe. Methods We performed a retrospective cohort analysis of all cases of carotid/cerebrovascular FMD presenting to our regional vascular service, by case-note review, and searching all relevant clinical databases. Results Eighty-six patients were identified between 1998–2020. Stroke or TIA was the most common mode of presentation. The most frequent vascular pattern was bilateral extracranial internal carotid artery FMD. Concomitant cerebrovascular complications - dissection, aneurysm or occlusive disease of the carotid, vertebral and cerebral vessels was common (41%) and included two cases of carotid cavernous fistula. FMD was also observed in the renal/visceral vessels and aorta in 13(15%) of the cohort (60% of those who had extracranial imaging), with 5% having aneurysm or dissection of other vessels. 19(22%) of patients required carotid/cerebrovascular intervention (mainly for intracranial aneurysm), with 10% requiring intervention for other vascular complications. Recurrent cerebrovascular events (stroke/TIAs and aneurysmal disease requiring intervention) was seen in 23% of cases. Overall mortality was 7% over a median follow-up period of 47 months. Conclusion The co-existence of intracranial aneurysm and other cerebrovascular complications in patients with carotid FMD is high and requires careful surveillance. Vascular complications in other vascular beds are also frequent and probably under-estimated. We would recommend a low threshold for routine imaging of all vascular beds in patients presenting with carotid/cerebrovascular FMD. Take-home message Fibromuscular dysplasia is rare but when presenting as a stroke, other vascular beds may be involved,

Atypical Presentation of Direct Carotid Cavernous Fistula

An atypical case of carotid cavernous fistula (CCF) is presented which was challenging to diagnose even with investigations. A 50-year old female, presented with complaints of increasing chemosis, diplopia and proptosis of her right eye following a fall from stairs. Her IOP was 32 mm Hg in right and 18 in left eye. Absence of other classic clinical signs like bruit/thrill of carotid cavernous fistula led to difficulty in diagnosing. There was absence of radiological evidence like enlargement of superior ophthalmic vein on MRI, MRV and MRA. We started symptomatic treatment for increased IOP and exposure keratopathy. Right sided CCF diagnosis was confirmed on CT angiogram and Digital Subtraction Angiography. Coil embolization was done which resulted in symptomatic and clinical relief. Carotid cavernous fistula with absence of typical signs is sometimes challenging to diagnose and treat. Importance of Digital Subtraction Study and CT Angiogram is highlighted.

Multimodal Management of Carotid-Cavernous Fistulas

Techniques for endovascular management of carotid-cavernous fistulas (CCFs) have evolved over the years. Current strategies include transarterial or transvenous approaches and direct puncture or exposure of the cavernous sinus. Rarely, complex CCFs may require multiple approaches or procedures. We describe our experience managing CCFs, reporting on outcomes and technical nuances. A retrospective review of institutional records was conducted to identify consecutive cases of CCF treated between July 2005 and July 2016. Pertinent technical details and outcomes were recorded. In 44 patients, 51 procedures were performed. There were 13 direct CCFs and 31 indirect CCFs: 13 (30%) type A, 3 (7%) type B, 5 (11%) type C, and 23 (52%) type D. A transarterial approach was selected in 39% of cases (n= 20), resulting in a long-term successful embolization rate of 60% (n= 12). Transvenous methods via the inferior petrosal sinus or superior ophthalmic vein were used in 49% of cases (n= 25), resulting in a long-term obliteration rate of 88% (n= 22). Multimodal management was required in 5 patients, including 1 patient in whom a craniotomy was performed to facilitate coil embolization of the cavernous sinus under direct vision. A 7% complication rate (n= 3) was observed, with significant morbidity in 1 patient. CCFs are complex vascular lesions that require facility with various endovascular and surgical approaches. High-flow, direct-type fistulas may harbor a significant risk of recurrence after transarterial embolization. Partial or unsuccessful embolization may necessitate an open surgical approach to the superior ophthalmic vein or cavernous sinus.

Comparison between different modalities of Endovascular treatment in Carotid Cavernous Fistula (CCF) and its short term outcome – Our Experience

Introduction: Endovascular treatment offers different technique (Balloon assisted coiling / simple coiling, glue embolization) to treat Carotid Cavernous Fistula (CCF). This less invasive approach avoids morbidity and residual fistulas. The choice of treatment depends on the anatomy of the fistulas and cost effectiveness.
 Objective: To describe different endovascular treatment option of Carotid Cavernous fistulas (CCF), its short term outcome (clinical and angiographical) and to compare between trans-venous coiling and trans-arterial balloon assisted sinus coiling.
 Method: We have treated nine (9) cases of CCF during a period of three years. Out of them eight patients had direct CCF and one had indirect CCF. In two patients simple coiling done through trans-venous route and in another three patients through trans-arterial route. Balloon assisted coiling through trans-arterial route done in three patients. In two patients trans-arterial glue embolization was done.
 Results: Successful obliteration of fistula was achieved in all cases. Vision was improved in eight (8) patients. Postoperatively some proptosis remains in two patients. In one patient there was reappearance of proptosis two months after treatment, then balloon assisted coiling was done. One patient died from complication of glue (NBCA). Conclusion: Endovascular treatment is the mainstay of treatment in CCF. Trans-venous is the treatment of choice but recently balloon assisted sinus coiling through trans-arterial route is adopted.
 Bang. J Neurosurgery 2019; 8(2): 68-76

Endovascular Occlusion of Traumatic Carotid Cavernous Fistula by Using Detachable Balloon in Various Ways: A Case Series

Abstract Introduction The detachable balloons are not frequently used nowadays for endovascular occlusion of carotid-cavernous fistula (CCF) because of lack of availability and supposed high risk of recurrence. This study describes the various way of detachable balloon embolization for traumatic CCF. Materials and Methods We have used endovascular detachable balloon to occlude the traumatic CCF under local anesthesia in various ways in 12 traumatic cases of CCF from March 2013 to April 2015. Clinical and computed tomographic (CT) angiography follow-up was done at 6 and 12 months. Results Clinical follow-up from 6 to 12 month showed persistent resolution of symptoms in 10 cases; 2 cases had developed slight proptosis and chemosis. CT angiography done in nine cases after 6 to 9 months showed no residual filling in CCF. Conclusion The detachable balloon either single or double with or without coils can be used in the management of CCF by different methods. Detachable balloon is a cheaper alternative compared with coiling. It is technically easier to perform and can be performed under local anesthesia.

Direct carotid-cavernous fistulas occurring during neurointerventional procedures

This study shows the frequency and types of carotid-cavernous fistula (CCF) complications that occurred during endovascular treatment. Transarterial endovascular surgeries involving the anterior circulation were performed for 1071 cases at our hospitals during four years. CCFs occurred in nine of 1071 cases (0.8%). CCF risk factors were female sex (p=0.032), aneurysmal location in the paraclinoid portion (p<0.001), and use of a distal access catheter (DAC) (p<0.001). There were no significant correlations between CCF risk and procedure type (p=0.411-1.0) and balloon use or nonuse (p=0.492). Eighty-nine percent (eight of nine) of the CCFs occurred at the genu of a cavernous internal carotid artery (ICA). Two cases of CCF disappeared spontaneously. The shunt was decreased by balloon expansion in one case, no additional treatment was required in one case, and five cases required transarterial fistula coil embolization. It is necessary to remember that a CCF may occur especially in aneurysmal treatment using a DAC in a female patient. The DAC and the 0.035-inch guidewire should be kept proximal to the carotid siphon and not go beyond it. When we cannot avoid navigating beyond it, we should consider using a softer DAC. In the case of a CCF caused by a DAC, it may be cured spontaneously or is treatable by transarterial coil embolization.

Carotid-cavernous fistula as a mimicker of myasthenia gravis

Background:A carotid-cavernous fistula (CCF) is an abnormal communication between the carotid arterial system and the cavernous sinus. Common symptoms of CCFs include proptosis and ophthalmoplegia, but fluctuating diplopia and presence of ptosis are not typical.Case Description:We present an unusual case of CCF with fluctuating binocular diplopia and ptosis, mimicking myasthenia gravis. Electrodiagnostic testing, which included repetitive nerve stimulation and single-fiber electromyography, was normal. Magnetic resonance imaging of the brain and orbits was initially normal, but later magnetic resonance angiography revealed enlargement of the left superior ophthalmic vein along with a left CCF. Patient underwent a successful left cavernous sinus embolization.Conclusion:Fluctuating ophthalmic symptoms are a typical presentation of myasthenia gravis; however, there may be an association of these symptoms with a CCF. Repetitive nerve stimulation and single-fiber electromyography played a key role in diagnosis of this case, as the normal result led to further investigations revealing a CCF.

Alteration of choroidal thickness in a case of carotid cavernous fistula: a case report and a review of the literature

BackgroundTo measure the alterations of the choroidal thickness in Carotid cavernous fistula (CCF) using enhanced depth imaging optical coherence tomography (EDI-OCT).Case presentationA 64-year-old woman was referred to us for redness, exophthalmos and visual disturbance in her right eye. She was diagnosed with CCF by magnetic resonance imaging (MRI) and magnetic resonance angiography.Observations; Embolization resulted in improvement of ocular symptoms, and there was a reduction of the subfoveal choroidal thickness in the right eye from 351 μm preoperatively to 142 μm postoperatively in EDI-OCT.ConclusionEDI-OCT demonstrated that the choroidal thickness increases occurred due to congestion in a CCF case.

Susceptibility-Weighted Imaging in Carotido-Cavernous Fistulas

This study determined the utility and accuracy of susceptibility-weighted MRI (SWI) for the detection of carotid cavernous fistulas. We retrospectively compared SWI images in nine patients (Group 1, case group) of DSA-proved carotid cavernous fistula (CCF) and 19 DSA negative cases for CCF as a control group (Group 2). Group 1 was again sub-grouped into direct and indirect types. Using uniform region-of-interest measurements, signal intensity within the superior ophthalmic vein (SOV) and the superior sagittal sinus (SSS) were measured on magnitude images of SWI. The SOV/SSS signal intensity ratio was calculated in each case and the mean values of the two groups were compared. Eleven SOV/SSS signal intensity ratios in Group 1 (7 unilateral and two bilateral CCF), 38 in Group 2 (both sides in 19 control subjects) were included. Median ± interquartile range of SOV/SSS ratios for Group 1, Group 2, indirect and direct type CCFs were 1.07 ± 0.43, 0.39 ± 0.23, 0.83 ±0.29, 1.4 ±0.38 respectively. Mann-Whitney test between Groups 1 and 2 was statistically significant with P<0.0001. All cases and controls were reliably distinguished with SOV/SSS signal intensity ratio of 0.64 as cut-off. Direct CCF cases had consistently higher ratios than indirect CCF. SWI was highly sensitive for detection and differentiation of both direct and indirect CCF. Only one case of corticovenous reflux was missed by SWI. SWI is useful for detection of CCF and to differentiate between direct and indirect CCF.

Posttraumatic Carotid-Cavernous Fistula Associated with Evolving Contralateral Internal Carotid Artery Pseudoaneurysm

Head trauma can result in vascular injuries at the base of skull. We present a unique case of carotid-cavernous fistula (CCF) on one side with evolving contralateral internal carotid artery (ICA) aneurysm resulting from a single trauma. There were different pathomechanisms involved in the development of these lesions. Both these lesions were successfully managed with endovascular coiling. The case cautions us about a potential threat of another delayed lesion forming on contralateral side once an ipsilateral posttraumatic vascular lesion has been treated. The case also highlights the importance of carefully looking for the ICA on both sides during digital subtraction angiography in trauma patients.

Endovascular treatment of carotid cavernous fistulae (CCF). Direct venous puncture using road mapping in dural CCF

IntroductionEndovascular treatment offers different options to treat CCF by less invasive approach avoiding morbidity and residual fistulas. The choice depends on the anatomy of the fistula and operator/Institutional preferences. ObjectiveDescribe options in endovascular treatment of Barrow Type A and Type D Carotid Cavernous fistulas (CCF). Patients and methodsWe report 10 cases of carotid cavernous fistula (CCF) that received endovascular treatment using coils and liquid embolic materials. Seven cases Barrow Type A, done through an arterial approach and three cases Barrow Type D, done through venous approach. The cavernous sinus in Type D cases was approached via the inferior petrosal sinus in one case and the other two cases by direct puncture of the facial and supra-orbital veins using road mapping. Using road mapping in venous approach to treat CCF is not reported in the literature before. ResultsSuccessful obliteration of the fistula was achieved in all cases with transient VI nerve palsy in one case and post procedure ophthalmic vein thrombosis in another. ConclusionWith the observed favorable outcomes and lack of significant procedural morbidity, direct puncture of the facial and supra-orbital veins using road mapping to reach the cavernous sinus, might be an addition in the armamentarium available for endovascular treatment of CCF.

O-033 A historical perspective on the treatment of carotid cavernous fistulas: The 16-year barrow neurological institute experience

Introduction/PurposeA carotid cavernous fistula (CCF) is a spontaneous or acquired connection between the carotid artery and cavernous sinus. These lesions classically present with chemosis, exopthalmos, and ocular bruit secondary to...

Involvement of Methicillin-Susceptible Staphylococcus aureus Related to Sequence Type 25 and Harboring pvl Genes in a Case of Carotid Cavernous Fistula after Community-Associated Sepsis

Staphylococcus aureus encoding Panton-Valentine leukocidin (PVL) genes has become the cause of life-threatening infections. We describe a case of carotid cavernous fistula after bacteremia in a 12-year-old male, caused by a methicillin-susceptible S. aureus isolate carrying the pvl, fnbA, and ebpS genes and related to sequence type 25 (ST25). The patient's condition was complicated by pleural empyema and osteomyelitis in the right femur. The patient was discharged in good clinical condition after 160 days of hospitalization.

A new transvenous approach to the carotid-cavernous sinus via the inferior petrooccipital vein

The transvenous approach via the inferior petrosal sinus (IPS) is commonly used as the most appropriate for carotid-cavernous fistula (CCF) or cavernous sinus sampling. However, sometimes the IPS is not accessible because of anatomical problems and/or complications, therefore an alternative route is needed. In this paper, the authors present and discuss the utility of a transvenous approach to the cavernous sinus via the inferior petrooccipital vein. Four patients, 3 with dural CCFs and the other with Cushing disease, in whom endovascular surgical attempts failed using a conventional venous approach via the IPS, underwent a transvenous approach to the cavernous sinus via the inferior petrooccipital vein (IPOV). One dural CCF case had only cortical venous drainage, the second CCF also mainly drained into the cortical vein with slight inflow into the superior ophthalmic vein and inferior ophthalmic vein, and the third demonstrated drainage into the superior and inferior ophthalmic veins and IPOV. In all cases, the cavernous sinus could be accessed successfully via this route and without complications. The transvenous approach to the cavernous sinus via the IPOV should be considered as an alternative in cases when use of the IPS is precluded by an anatomical problem and there are no other suitable venous approach routes.

Transorbital Endovascular Embolization of Dural Carotid-Cavernous Fistula: Access to Cavernous Sinus through Direct Puncture: Case Examples and Technical Report

We present 2 cases of carotid-cavernous fistulas that failed multiple attempts at transarterial and transvenous embolization. Direct transorbital puncture for embolization was successful in curing the fistulas. The relevant anatomy and technique are reviewed. The first case is a 39-year-old man who presented with a 2-month history of worsening right-sided chemosis, proptosis, double vision, and progressive right eye vision loss. The second case is a 79-year-old woman with a 5-month history of right-sided chemosis and a 1-month history of complete left ophthalmoplegia. Cerebral angiography revealed an indirect carotid-cavernous fistula (CCF) in both patients, supplied by meningeal branches of the internal and/or external carotid arteries. After multiple unsuccessful attempts at transarterial and transvenous embolization, the CCFs were accessed via direct percutaneous transorbital puncture of the inferior and superior ophthalmic veins, respectively. The fistulas were then successfully occluded with a combination of Onyx and detachable coils. In rare cases in which more conventional transvenous and transarterial routes to a CCF have been exhausted, direct percutaneous transorbital puncture represents a viable means of achieving catheterization of the fistulous connection. In most cases, where a prominent arterialized superior ophthalmic vein is present, direct puncture represents a reasonable alternative to ophthalmologic cut-down procedures. Transorbital puncture of the inferior ophthalmic vein provides a direct route to the cavernous sinus in cases where the superior ophthalmic vein is atretic and inaccessible by direct surgical cut-down procedures.

Carotid cavernous fistulas treated by endovascular covered stent grafts with follow-up results

Historically, carotid cavernous fistulas (CCFs) are usually treated with detachable balloons and coils. While coronary covered stent grafts have been sporadically used in the intracranial vasculature, only a few such cases have been reported in the literature. We present our experience of seven patients with eight CCFs, treated by the placement of covered stents, and provide their clinical and angiographic follow-up results. From 28 cases of CCF treated at our department between November 2000 and January 2007, a total of eight post-traumatic CCF were treated between May 2005 and January 2007 by positioning a Jostent coronary stent graft (Abbott Vascular, Redwood City, CA) in the intracranial ICA. These patients had periodic follow-up examinations (at 12–30 months) with 5 of them receiving a follow-up angiographic examination (at 6–9 months). Immediate post-procedural angiograms demonstrated total exclusion in five CCFs, residual filling in three CCFs, and preserved ICA patency in all CCFs. Symptoms related to the CCF regressed within 1–15 days after the covered stent placement. There was no mortality and no immediate post-procedural morbidity related to the CCF covered stent treatment; however, one patient died of acute myocardial infarction in 10 days following treatment. Six patients showed complete clinical recovery during their clinical follow-up. The angiographic follow-up (mean, 8 months) in five patients with six CCFs revealed regressed residual filling, stable occlusion of all CCFs, and an ICA patency (one case of asymptomatic ICA occlusion) rate of 83.3%. Covered stents are a promising therapeutic alternative for patients with CCF in whom fistulas cannot be successfully occluded with detachable balloons or coils. Our results and the reported results showed that a covered stent could occlude the fistula and preserve the ICA without hemodynamic changes or negative clinical effects. Covered stent grafts could soon become a first-line therapy as experience with this device increases, materials continue to improve, and more data are accumulated.