Treatment of Barrow type ‘B’ carotid cavernous fistulas with flow diverter stent (Pipeline)

Abstract

Background Carotid cavernous fistulas (CCFs) Barrow type 'B' are dural shunts between the meningeal branches of the internal carotid artery and the cavernous sinus. The symptoms include vision deterioration, ophthalmoplegia with diplopia, exophthalmos, conjunctival injection, chemosis, ocular bruit, seizures, or neurological deficit. Endovascular treatment remains the gold standard for treatment through the transvenous or transarterial routes. The transvenous approaches have been proved to be the first option. Endovascular access through the superior ophthalmic vein (SOV) or inferior petrosal sinus have been widely used. The problem arises when there is no vascular access. For these cases, different approaches have been described, such as: direct access to the SOV; combining direct access to the SOV along with blind probing of the proximal occluded SOV; and a direct puncture of the cavernous sinus. But these techniques are very aggressive and can cause serious complications. As a result of the above, we describe a new alternative technique, which is effective and less invasive for the treatment of these special cases. Case reports We report two cases of Barrow type 'B' CCFs that did not have vascular access (neither arterial nor venous) to embolise fistulas with coils or glue, and which were successfully resolved with a flow diverter (Pipeline) stent in the internal carotid artery. To our knowledge, this treatment has not previously been described for this pathology. Conclusions The placement of a flow diverter stent in the internal carotid artery is an effective alternative technique in those cases of Barrow type 'B' CCFs that have no vascular access (neither venous nor arterial).

XCalibur aneurysm occlusion device for the treatment of direct carotid cavernous fistula: expansion of armamentarium

“…There have been many publications on the treatment of direct CCFs (Barrow type A) using a flow diverter alone or as an adjunct to coils or Onyx embolization. Flow diverters have also been used to treat Barrow type B CCFs6 and fistulas developing secondary to cavernous ICA aneurysm rupture after flow diverter treatment 7. In the study by Wendl et al 4 only five out of 14 patients could be successfully treated using a flow diverter alone 4…”

Updates in the management of cranial dural arteriovenous fistula

“…Although in the past, detachable balloons, polyvinyl alcohol, silk sutures and microspheres were used for treatment of cerebral AVM and dAVFs they have been widely replaced by current embolic agents, including n -butyl-2-cyanoacrylate ( n -BCA, glue, Trufill, DePuy Synthes, Raynham, MA), Onyx (ev3 Endovascular, Irvine, CA), Squid (Emboflu, Switzerland), precipitating hydrophobic injectable liquid (PHIL; MicroVention, Aliso Viejo, California) and detachable microcoils. Recent advancements have introduced newer embolic agents, such as PHIL12 and Squid (Emboflu),13 and flow diverters, such as the pipeline embolisation device (Medtronic Neurovascular, Irvine, California), to treat AVFs and inhibit fistula recanalisation in special scenarios,14 as described by Castãno et al with the treatment of two Barrow type B indirect carotid cavernous fistula (CCF), a version of dAVF. Classic approaches described for endovascular treatment of dAVFs include transarterial, transvenous or a combination of both techniques.…”

“…While flow-diverting stents have been used to treat direct CCFs,31 there is limited efficacy for treatment of the most common dAVF because of lesion complexity including multiple arterial feeders’ origins (ECAs, ICAs and vertebral arteries). However, Castãno and colleagues reported two cases of indirect CCF (Barrow type B), a version of dAVF in which all arterial feeders were originated from ICA, that were successfully treated with the Pipeline Flex embolisation device with shield technology (Medtronic) 14. Endothelialisation of the flow-diverting stent allowed for occlusion of the many arterial branches feeding the fistula.…”

Results of Endovascular Treatment for High-Flow Direct Carotid-Cavernous Fistulas

“…[9] и открыло новую эру в лечении данной патологии. Методика их применения заключается во введении сдутого баллона непосредственно в дефект ВСА с последующим его раздутием до размера, превышающего дефект артерии, для того чтобы предупредить миграцию в просвет ВСА, после чего баллон отделяется от микрокатетера [7,[9][10][11]. Преимуществом данной методики является возможность быстрого закрытия фистулы, однако некоторые авторы [6] также обращают внимание на невозможность адекватного использования баллона в случае слишком большого или малого размера артериального дефекта, вследствие чего доставка баллона непосредственно в дефект может быть затруднена.…”

“…Вместе с тем разработка в дальнейшем более гибких стентов может привести к доминированию этого метода благодаря его простоте и быстроте выключения соустья [18]. Для лечения ККС также предложена методика установки в просвет ВСА потокоперенаправляющего стента [2], однако некоторые авторы склоняются к мнению, что данный метод более подходит для лечения непрямых низкопотоковых соустий [10].…”