Direct Carotid Cavernous Fistulas

Abstract

A direct carotid cavernous fistula (CCF) is an abnormal shunt between the internal carotid artery (ICA) and the cavernous sinus (CS). Traumatic CCF is the most common type, accounting for up to 75% of all CCFs. For the management of direct CCF, endovascular therapy has become the standard. For successful endovascular therapy, evaluation of the size and location of orifice of the CCF, venous drainage, and tolerance for ICA occlusion on cerebral angiography is necessary. Multi-planner reformatted images of 3D rotation angiography are useful to visualize the fistula and compartments of the CS precisely. Due to the limited commercial availability of detachable balloons, detachable coils have become a widely employed endovascular tool for the treatment of direct CCFs. The advantageous aspects of coil application are their easy retrievability and better control. In the case of large/multiple fistulas, adjunctive techniques, including balloon-and stent-assisted techniques, are often needed to occlude the CCF while preserving the ICA. To avoid cranial nerve palsy related to over-packing of the CS with detachable coils or a detachable balloon, selective embolization of the fistula portion is required. Use of liquid embolic materials and covered stents was recently reported as another adjunctive technique. In cases in which it is impossible to occlude the CCF while preserving the ICA, parent artery occlusion (PAO) is considered. The selection of additional/alternative techniques and devices depends on the anatomy and hemodynamics of each CCF, and the skill and experience of individual operators. Keywords▶ direct carotid cavernous fistula, transarterial embolization, transvenous embolization, coil embolization, detachable balloon Traumatic CCF is the most common type, accounting for up to 75% of all CCFs. 1,2) The shunt flow in direct CCFs is generally markedly high and causes numerous symptoms, including exophthalmos, diplopia, epistaxis, and cerebral hemorrhage. Emergency treatment is often required in cases with severe symptoms and high-risk venous drainage. Cases of direct CCF used to be mainly treated by muscle occlusion, carotid artery ligation, or a combination of these methods. Following the advent of useful devices, such as detachable balloons and coils, endovascular therapy has become the standard management for direct CCFs. To evaluate the size and location of a fistula, and tolerance for ICA occlusion, cerebral angiography is an important examination. The treatment method depends on angiographic findings. This review presents important issues for the treatment of direct CCFs.

Treatment of Traumatic Direct Carotid-Cavernous Fistula with a BeGraft-Covered Stent

“…1 Following the unavailability of the detachable balloon in the market, coils have been replaced, and transarterial and/or transvenous coil embolization has become the standard treatment of dCCF. 2 Despite the high efficacy of coiling for fistulae occlusion, the preservation of the internal carotid artery (ICA) and its reconstruction are not usually possible and can lead to complete ICA occlusion. 3 Alternately, new methods have been applied for better occlusion of the fistula with preservation of the ICA, such as stent-assisted coiling, balloon-assisted coiling, embolization with liquid embolic agents like Onyx, flow-diverters, and covered stents.…”

“…3 Alternately, new methods have been applied for better occlusion of the fistula with preservation of the ICA, such as stent-assisted coiling, balloon-assisted coiling, embolization with liquid embolic agents like Onyx, flow-diverters, and covered stents. 2 Over the last 2 decades, covered stents have emerged as a novel method to reconstruct ICA walls as well as the occlusion of the CCF. 4 In the current study, we present initial and long-term angiographic outcomes of dCCF treatment with the BeGraft-covered stent (Bentley InnoMed GmbH) to evaluate its efficacy and safety.…”

“…With the advent of the detachable balloon, transarterial endovascular surgery became the mainstay treatment of direct carotid-cavernous fistula (dCCF) since 1980 [ 1 ]. Following the unavailability of the detachable balloon in the market, coils have been replaced, and transarterial and/or transvenous coil embolization has become the standard treatment of dCCF [ 2 ]. Despite the high efficacy of coiling for fistulae occlusion, the preservation of the internal carotid artery (ICA) and its reconstruction are not usually possible and can lead to complete ICA occlusion [ 3 ].…”

“…Alternately, new methods have been applied for better occlusion of the fistula with preservation of the ICA, such as stent-assisted coiling, balloon-assisted coiling, embolization with liquid embolic agents like Onyx, flow-diverters, and covered stents [ 2 ]. Over the last 2 decades, covered stents have emerged as a novel method to reconstruct ICA walls as well as the occlusion of the CCF [ 4 ].…”