Artificial embolization of carotid-cavernous fistula with post-operative patency of internal carotid artery

Abstract

SUMMARY This report deals with a patient of 86 who developed a carotid-cavernous fistula. Artificial embolization alone was considered the safest treatment for this patient and proved to be adequate. Post-operative preservation of the patency of the internal carotid artery was demonstrated by angiography. We believe this method is particularly appropriate for carotid-cavernous fistulas if it is demonstrated by angiography that the major blood flow of the carotid artery pours into the fistula. A soft-iron clip attached to the muscle can be used for external and forceful guidance of the embolus into the fistula with the help of an electromagnet, hence the patency of the internal carotid artery can be preserved. The embolus should be introduced through the external carotid artery. This is the only case known to us in which patency of the internal carotid artery was postoperatively maintained. We have reviewed 545 reported cases of surgically treated carotid-cavernous fistulas and analysed the results from simple cervical carotid ligation to the more sophisticated methods of artificial embolizations. The results obtained by artificial embolization have been consistently good, while the other techniques have failed in large percentages. Artificial embolization should be used as the primary treatment for carotid-cavernous fistula, since ligation of the internal carotid artery precludes its embolization at a later date.Because of the dramatic and intense disability produced by a carotid-cavernous fistula this intracranial vascular pathology has had considerable surgical attention in spite of the low rate of incidence. A variety of surgical techniques have been developed but most of the surgical approaches have dealt with a distant reduction of the blood flow into the fistulous tract rather than with the closure of the fistula itself. Examples are the single or combined ligation of the carotid arteries in the neck and isolation of the fistula between an intracranial carotid clip and a cervical carotid ligation, the so-called 'trapping' operation.The first attempt to treat a carotid-cavernous fistula with a physiological approach to the problem was that of Brooks (1930) who successfully performed a muscle embolization of the intracavernous portion of the carotid artery. Since then a limited number of artificial embolizations with surgical (Hamby

The myth of the Brooks method of embolization: a brief history of the endovascular treatment of carotid–cavernous sinus fistula

“…In 1965 Lang and Bucy,13 under the impression that they were employing ‘Brooks' method’ embolized CCSF with a small piece of muscle resulting in cure of the fistula with thrombosis of the ICA. It is true that Isamat et al ,21 under the impression that they were using Brooks' method, were the first to embolize free muscle with a silver clip eliminating CCSF while simultaneously recording patency of the ICA However, they described only one patient, who expired shortly thereafter and an autopsy was not obtained. From our review it is also apparent that, with few exceptions, the overwhelming majority of the authors never read Brooks' publications 6.…”

“…In 1970 Isamat et al 21 were the first who reported truly accomplishing embolization of the CCSF with a free piece of muscle and maintaining patency of the ICA. The patient was an 86-year-old woman.…”

Embolizaçao de fístula carótido-cavernosa com conservação da circulação arterial: registro de um caso

“…Em 1935 Dandy 6 publicou dois casos com resultados satisfatórios. O índice de cura tem sido de 78% com a exclusão da artéria oftálmica e 57% sem a exclusão (Isamat e col. 13 ). A ligadura da artéria oftálmica não costuma determinar complicações visuais se a artéria carótida externa for poupada, pois doze ramos colaterais a suprem (Echols & Jackson 7 ).…”

“…Essa técnica tem porcentagem de cura de 90% dos casos. A mesma técnica com êmbolos pequenos tem sido defendida por Hamby e Gardner 10 , Yasargil 32 , Isamat e col. 13 , Le Xuan Trung e col. 1 », Blach e col.* e Ohta e col. 22 com cerca de 30 casos registrados; o tamanho do embolo varia do de uma ervilha ao de um grão de arroz; o material tem sido principalmente músculo. Kosary e col. 14 tem usado bolinhas de porcelana e gelfoan e Ohta e col. 22 poliuretano; normalmente são usados dois a três êmbolos.…”

Surgical management of an unusual carotid-cavernous fistula

“…All the embolization procedures described to occlude such a fistula (Isamat et al, 1970) were ruled out because of the internal carotid thrombosis. Simple clipping of the carotid artery inside the skull, as advised by Dandy (1935), was estimated to be an insufficient measure because of the good filling of the fistula through the ophthalmic artery.…”