Endovascular Treatment of Traumatic Carotid Cavernous Fistula with Balloon-Assisted Sinus Coiling

Abstract

<jats:p> This study aimed to propose an alternative treatment for carotid cavernous fistula (CCF) using the balloon-assisted sinus coiling (BASC) technique and to describe this procedure in detail. </jats:p><jats:p> Under general anesthesia, we performed the BASC procedure to treat five patients with traumatic CCF. Percutaneous access was obtained via the right femoral artery, and a 7F sheath was inserted, or alternatively, a bifemoral 6F approach was accomplished. A microcatheter was inserted into the cavernous sinus over a 0.014-inch microwire through the fistulous point; the microcatheter was placed distal from the fistula point, and a “U-turn” maneuver was performed. Through the same carotid access, a compliant balloon was advanced to cross the point of the fistula and cover the whole carotid tear. Large coils were inserted using the microcatheter in the cavernous sinus. Coils filled the adjacent cavernous sinus, respecting the balloon. </jats:p><jats:p> Immediate complete angiographic resolution was achieved, and an early angiographic control (mean = 2.6 months) indicated complete stability without recanalization. The clinical follow-up has been uneventful without any recurrence (mean = 15.2 months). </jats:p><jats:p> An endovascular approach is optimal for direct CCF. Because the detachable balloon has been withdrawn from the market, covered stenting requires antiplatelet therapy and its patency is unconfirmed, but cavernous sinus coiling remains an excellent treatment option. Currently, there is no detailed description of the BASC procedure. We provide detailed angiograms with suitable descriptions of the exact fistula point, and venous drainage pathways. Familiarity with these devices makes this technique effective, easy and safe. </jats:p>

Transvenous Target Embolization for a Small Sized, Non-traumatic Direct Carotid-cavernous Fistula using a Single Coil: Technical Case Report

“…Another study presented five patients who underwent transarterial embolization with a balloon for the ICA, with a mean coil count of 11.2 (6-18). 11) In these studies, the number of coils was within the permissible range, but it is difficult to stabilize a coil in the venous sinus using a transarterial approach; the number of coils tends to be large. If a microcatheter is guided from the venous side, the fistulous site may be embolized in a narrow extent by occluding the ICA side with a balloon to prepare a wall; therefore, in the present case, we selected a transvenous approach.…”

Endovascular treatment of carotico-cavernous fistulas with acrylic glue: a series of nine cases

“…The technique is previously described [3] and will in most cases be sufficient, and is advocated in cases of aneurysmal rupture as underlying cause for the CC-fistula. However, coil compaction with subsequent risk of recanalization still constitutes a caveat to this technique.…”

“…With the development of endovascular techniques, alternative treatments have been performed via both intraarterial and intravenous approaches [3–7], using a variety of embolic materials, as detachable latex balloons, coils, covered stents, or combinations of these methods. Detachable latex balloons have been considered as the most appropriate tool to occlude a CCF because of their safety of use and affordable price.…”

Treatment of direct carotid–cavernous fistulas with a double lumen balloon

“…Balloon assisted coil embolization of traumatic dCCFs has also been described 12. In the case series by Andrade et al , a compliant single lumen balloon was positioned along the carotid tear and used for balloon remodeling of the ICA during coil embolization of the cavernous sinus.…”