Treatment Of Direct Carotid-cavernous Fistula Research Articles

Three-dimensional fusion images from digital subtraction angiography for the treatment of direct carotid-cavernous fistulas: illustrative case.

Direct carotid-cavernous fistulas (dCCFs) are often treated endovascularly. However, because the dCCF is usually a high-flow shunt, it is often difficult to obtain an accurate vascular structure using conventional digital subtraction angiography (DSA). Here, the authors report a case of successfully treated dCCF using three-dimensional (3D) fused DSA images. The patient presented with tinnitus, followed by oculomotor palsy, prompting magnetic resonance imaging that indicated a dural arteriovenous fistula of the cavernous sinus. DSA was performed before treatment, and a diagnosis of dCCF due to a ruptured aneurysm was made. In this case, the 3D fused simulation images enabled the authors to obtain an accurate vascular structure, resulting in successful coil embolization. Three-dimensional fusion images from DSA provide detailed anatomical information and are useful for treating high-flow dCCFs.

Treatment of direct carotid-cavernous fistula with Willis covered stent with midterm follow-up

BackgroundWillis covered stent is the first stent designed exclusively for intracranial vasculature, and its application in carotid-cavernous fistula is limited. The aim is to evaluate the feasibility and efficacy of this device in treating direct carotid-cavernous fistula.MethodsTen consecutive patients with direct carotid-cavernous fistula were treated in our institution with Willis covered stents from September 2013 to December 2015. The characteristics of these patients and the immediate and follow-up results were retrospectively reviewed.ResultsOf the 10 patients, 8 were treated for the first time, and 2 had been treated elsewhere. Willis covered stents were successfully released in 9 patients. Abnormal arteriovenous shunt disappeared in 6 cases immediately after stent deployment and endoleak occurred in 3 cases. Endoleak disappeared at 6-month angiography follow-up in one case and was sealed with coils through a pre-set microcatheter in another case. Parent artery was sacrificed as endoleak remained despite repeated balloon dilation and a second stent deployment in the third case. All patients got clinical follow-ups for at least 24 months and 7 patients received angiographic follow-up. Symptoms were relieved gradually in all cases except for slight oculomotor paralysis and visual acuity in one case, respectively. In-stent stenosis was found in 1 case, and no recurrence was observed.ConclusionsWillis covered stent is feasible for direct carotid-cavernous fistula.

Transarterial and Transvenous Coil Embolization of Direct Carotid-Cavernous Fistulas.

Transvenous embolization (TVE) is typically used in combination with the residual shunt of transarterial embolization (TAE) for the treatment of direct carotid-cavernous fistulas (direct CCFs). This report is about our additional embolization method using combination therapy. Five consecutive cases of direct CCF were presented; two were caused by aneurysms and three by head injuries. The treatment for each was started with TAE, with the addition of TVE if a shunt remained. At the time of TVE, a microcatheter positioned in the internal carotid artery passing from the cavernous sinus through the aneurysm neck or fistula was pulled back (pull-back method). It was then placed in the coil mass with TAE, and additional coils were filled. In two cases, the shunt disappeared by using only TAE, whereas it disappeared after being additionally embolized by the pull-back method in the remaining cases. All patients recovered with no postoperative complications. The TAE and TVE combination therapy with the pull-back method could efficiently embolize the residual shunt after TAE.

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

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. We present 3 cases and review the existing literature. 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. 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.

Advances in the endovascular treatment of direct carotid-cavernous fistulas.

Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus. They are considered direct when there is a direct connection between the internal carotid artery and the cavernous sinus. These cases are generally traumatic. Direct CCFs are high-flow lesions, possibly related to intracranial bleeding, visual loss, corneal exposure or even fatal epistaxis. Treatment of such lesions is, thus, always recommended. The ideal treatment for direct CCF is to exclude the fistula from circulation, preserving the carotid flow. This can be attained using diverse endovascular techniques. The objective of the present article is to review the current techniques for treatment of direct CCFs, with special attention to the currently available endovascular treatment options.

Covered stents for the endovascular treatment of a direct carotid cavernous fistula : single center experiences with 10 cases.

ObjectiveCovered stent has been recently reported as an effective alternative treatment for direct carotid cavernous fistulas (DCCFs). The purpose of this study is to describe our experiences with the treatment of DCCF with covered stents and to evaluate whether a covered stent has a potential to be used as the first choice in selected cases.MethodsFrom February 2009 through July 2013, 10 patients underwent covered stent placement for a DCCF occlusion. Clinical and angiographic data were retrospectively reviewed.ResultsCovered stent placement was performed for five patients primarily as the first choice and in the other five as an alternative option. Access and deployment of a covered stent was successful in all patients (100%) and total occlusion of the fistula was achieved in nine (90%). Complete occlusion immediately after the procedure was obtained in five patients (50%). Endoleak persisted in five patients and the fistulae were found to be completely occluded by one month control angiography in four. The other patient underwent additional coil embolization by a transvenous approach. Balloon inflation-related arterial dissection during the procedure was noted in two cases; healing was noted at follow-up angiography. One patient suffered an asymptomatic internal carotid artery occlusion noted seven months post-treatment.ConclusionAlthough endoleak is currently a common roadblock, our experience demonstrates that a covered stent has the potential to be used as the first choice in DCCF; this potential is likely to increase as experience with this device accumulates and the materials continue to improve.

P-026 Endovascular Treatment as a Resolutive Method of Carotid-Cavernous Fistulas with Detachable Balloons

IntroductionThe cavernous sinus (CS) is a complex structure that has been studied since decades. An abnormal communication between the Carotid Artery and the CS is known as Carotid-Cavernous Fistula (CCF)...

内頚動脈海綿静脈洞瘻に対する塞栓術におけるEDコイルアンフィニの有用性

【目的】EDコイルアンフィニ®は，コイル2次径が大きく柔軟性が高い．今回我々は，EDコイルアンフィニ®を用いて塞栓術を施行した内頚動脈海綿静脈洞瘻の2症例を報告する．【症例1】83歳女性，右耳鳴にて発症した．EDコイルアンフィニ®を用いて経静脈的塞栓術を施行したところ，瘻孔部にコイルが充填され，シャント血流は消失した．【症例2】72歳女性，右耳鳴にて発症した．経動脈的および経静脈的に塞栓術を施行した．EDコイルアンフィニ®を主体に用いて海綿静脈洞を塞栓したところ，シャント血流は著明に減少した．【結論】内頚動脈海綿静脈洞瘻に対する塞栓術においてEDコイルアンフィニ®は有用であった．

Development of Indirect Cavernous Dural Arteriovenous Fistula after Trapping for Direct Carotid Cavernous Fistula

A 60-year-old man with direct carotid cavernous fistula (CCF) due to a motor vehicle accident underwent internal carotid artery trapping following high-flow external carotid to internal carotid artery bypass (EC-IC bypass). Follow-up angiography revealed ipsilateral complex indirect cavernous arteriovenous fistula. Although the traumatic indirect CCF angioarchitecture differs from cavernous-sinus dural arteriovenous fistula (CS-DAVF), the present indirect fistula was similar to the latter. Complex indirect CCF can occur after treatment of direct CCF caused by severe head injury.

Retinal neovascularization after internal carotid artery occlusion.

To report a case of retinal neovascularization after surgical ligation of the internal carotid artery for treatment of direct carotid-cavernous fistula. Case report. A 44-year-old Asian woman presented with unilateral retinal neovascularization and vitreous hemorrhage. Surgical ligation of the ipsilateral internal carotid artery had been performed 14 years earlier as a treatment for carotid-cavernous fistula after failed attempts at fistula embolization. Vitrectomy was performed for removal of nonclearing vitreous hemorrhage, with intraoperative peripheral retinal ablation and cryotherapy of the lesion. We report a case of retinal neovascularization associated with total occlusion of the ipsilateral internal carotid artery 14 years earlier.

Follow-up of endovascular treatment of direct carotid-cavernous fistulas

Direct carotid-cavernous fistula (CCF) is a direct communication between the internal carotid artery (ICA) and the cavernous sinus. Some patients treated with detachable balloons develop pseudoaneurysms or present with a true aneurysm recanalization in the cavernous ICA with poorly known long-term radiological and clinical progression. The objective of the present study was to evaluate the long-term clinical and radiological progression of patients treated with detachable balloons. The present study evaluated 13 patients previously treated for direct CCF by an endovascular approach. The follow-up period ranged between 19 and 128 months. Ophthalmological evaluation demonstrated alterations in eight patients (61.5%). All of these alterations were already present from the moment of the treatment and displayed no signs of progression. Cranial magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were performed in all patients, and 11 pseudoaneurysms were demonstrated in ten of the 11 patients in whom ICA patency had been preserved. Five patients were submitted for cerebral digital subtraction angiography (DSA) to characterize the pseudoaneurysms previously observed on MRA studies, with no significant differences in morphology, size, aneurismal neck, and number of lesions. Endovascular treatment of direct CCF with detachable balloons has been shown to be a long-term effective and stable therapeutic method. The authors found asymptomatic pseudoaneurysms in 91% of cases where the ICA patency was preserved. MRI and MRA demonstrated an accuracy similar to that of DSA in the diagnosis of pseudoaneurysms of cavernous ICA.

Covered Stent Implantation for the Treatment of Direct Carotid-Cavernous Fistula and its Mid-Term Follow-up

Carotid-cavernous fistulas are abnormal arteriovenous communications either directly between the internal carotid artery and the cavernous sinus or between the dural branches of the internal and external carotid arteries. These fistulas predominantly present with ocular manifestations and they are treated mainly by endovascular techniques in most cases. A detailed review of the literature allowed us to make a complete analysis of the information available on the topic. We describe a case of a direct carotid-cavernous fistula occluded by endovascular implantation of a covered stent, showing the persistence of results after three years.

Placement of Covered Stents for the Treatment of Direct Carotid Cavernous Fistulas

Endovascular detachable balloon occlusion and coil occlusion are 2 well-established options for the treatment of direct carotid cavernous fistulas (DCCFs). In recent years, covered stents have been applied in the treatment of neurovascular pathologies such as aneurysms, pseudoaneurysms, arterial dissections, and DCCFs. The purpose of this study was to investigate the clinical efficacy of covered stents for the treatment of DCCFs. Ten consecutive patients underwent covered-stent placement after failure of detachable balloon occlusion for the treatment of their DCCFs. Clinical and angiographic follow-up ranged from 5 to 48 months (mean, 18.2 months) after stent placement. Stent placement was technically successful in all except 1 patient. In this patient, stent placement failed after multiple attempts because of rigidity of the Jostent GraftMaster Coronary Stent Graft and the tortuous anatomy of the internal carotid artery (ICA). Complete exclusion of the fistula was achieved in 6 patients immediately after stent deployment. Endoleak was observed in 3 patients. Re-dilation of the stent avoided the endoleak in 2 patients; in 1 of these 2 patients, formerly improved symptoms recurred the next morning and the ipsilateral ICA was occluded with detachable balloons. Spasm of the ICA was observed in most of the patients after stent placement; however, angioplasty was not required. Symptoms improved in all patients after treatment, without thromboembolic events. Follow-up cerebral angiography showed complete exclusion of all DCCFs and stent patency without intrastent stenosis in the 8 patients who had successful deployment of the stent. Although a larger sample and expanded follow-up are needed, our series shows that covered stents can be used in the treatment of DCCFs with symptomatic relief.

Minimally Invasive Keyhole Approach for Removal of a Migratory Balloon Complicated by Endovascular Embolization of a Carotid-Cavernous Fistula

This report presents our experience in using a minimally invasive keyhole approach to remove a migratory balloon in the cerebral artery in one patient. A 19-year-old male suffered from carotid-cavernous fistula after craniofacial trauma two months previously. The patient received endovascular embolization of a carotid-cavernous fistula with detachable balloons. Unfortunately, migration of one balloon to the right middle cerebral artery (MCA) at the M1-M2 junction was noted after detaching the balloon during this procedure. Volume expansion, anticoagulation therapy and an emergency pterional keyhole approach with removal of the displaced balloon were performed successfully. Transient left hemiparesis due to temporary occlusion of the right middle cerebral artery by the balloon was promptly alleviated. There was no definite neurological sequel after the operation. Although detachable balloon embolization is the best initial treatment of direct carotid-cavernous fistulas, it is likely to migrate to downstream cerebral arteries. We recommend a minimally invasive pterional keyhole approach as a good alternative for treating such endovascular complications to improve outcome.

Treatment of Direct Carotid-Cavernous Fistulas with Detachable Balloons

Experience with transarterial treatment of 14 direct carotid-cavernous fistulas using the Debrun technique with detachable balloons manually tied to the catheter is reported. Ten of the fistulas were occluded by balloons with concomitant occlusion of the internal carotid in one case. Another fistula closed spontaneously in connection with the embolization procedure. Three fistulas were treated with surgical trapping after recurrence. The transvenous approach was attempted in three cases but failed. Four complications occurred, two with clinical consequences as the patients developed neurologic deficits. Except in four cases with persistent or slowly regressing orbital palsies all signs and symptoms of the fistula disappeared after successful occlusion. The use of detachable balloons for selective occlusion is in experienced hands a rather safe and simple method with good results. Large fistulas offer most problems, and to avoid progression in fistula size the treatment should be undertaken as soon as possible after diagnosis.

Treatment of Direct Carotid-Cavernous Fistulas with Detachable Balloons

Treatment of Direct Carotid-Cavernous Fistulas with Detachable Balloons