Treatment of carotid-cavernous fistulas using intraarterial balloon assistance: case series and technical note

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Multiple approaches have been used to treat carotid-cavernous fistulas (CCFs). The transvenous approach has become a popular and effective route. Onyx is a valuable tool in today's endovascular armamentarium. The authors describe the use of a balloon-assisted technique in the treatment of CCFs with Onyx and assess its feasibility, utility, and safety.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors searched their prospectively maintained database for CCFs embolized using Onyx with the assistance of a compliant balloon placed in the internal carotid artery (ICA).</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Five patients were treated between July 2009 and July 2011 at the authors' institution. A balloon helped to identify the fistulous point, served as a buttress for coils, protected from inadvertent arterial embolizations, and prevented Onyx and coils from obscuring the ICA during the course of embolization. No balloon-related complications were noted in any of the 5 cases. All 5 fistulas were completely obliterated at the end of the procedure. Four patients had available clinical follow-ups, and all 4 showed reversal of nerve palsies.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Balloon-assisted Onyx embolization of CCFs offers a powerful combination that prevents inadvertent migration of the embolic material into the arterial system, facilitates visualization of the ICA, and serves as a buttress for coils deployed in the cavernous sinus through the fistulous point. Despite adding another layer of technical complexity, an intraarterial balloon can provide valuable assistance in the treatment of CCFs.</jats:p></jats:sec>

Mid- and long-term outcomes of carotid-cavernous fistula endovascular management with Onyx and n-BCA: experience of a single tertiary center

“…Onyx precipitates into a cast gradually and in a radial fashion, allowing for more controlled injections 15 57. It is often especially useful for a transarterial approach and in complex CCFs with multiple arterial feeders, as the slower rate of Onyx precipitation allows the material to penetrate deeply into the fine, complex CCF arterial supply and reflux from the venous fistula site into other arterial pedicles, thus limiting the number of injections required.…”

Combined use of Onyx and coils for transarterial balloon-assisted embolization of traumatic carotid-cavernous fistulas: a report of 16 cases with 17 fistulas

“…Recently, coils and liquid embolization agents such as ethylene vinyl alcohol (Onyx; ev3 Endovascular) have increasingly been used in the treatment of CCFs 2–4. However, the combined use of coils and Onyx (called the ‘armored concrete’ treatment modality) has rarely been reported and case numbers are very limited 5 6. The purpose of the current study was to evaluate our preliminary experience with the use of the ‘armored concrete’ treatment modality to treat 16 patients with 17 traumatic CCFs.…”

Advances in the endovascular treatment of direct carotid-cavernous fistulas

“…This is achieved with the positioning of a latex balloon in the CS, occluding the fistula orifice. 4,6,8,14,15,20,28 Nevertheless, in some countries, such as the United States, detachable balloons are not used, 11 making another type of approach necessary. In addition, the failure rate for selective occlusion of the fistula with a balloon is as high as 10%.…”

“…Although the standard treatment for a direct CCF is most frequently performed via the artery, by means of selective occlusion of the fistula and preservation of the ICA patency with a balloon, the embolization of the affected CS using platinum coils and accessing the region by the transvenous route has been used currently, mainly due to safety of its execution and the high rate of success obtained. 12,28,33 Access through the ipsilateral jugular vein and inferior petrosal sinus (IPS) is the venous route most often used for access to the affected CS. 4,8,12,35 After positioning the microcatheter in this CS, the occlusion of the sinus, and consequently of the fistula, can be performed using a detachable balloon, detachable coils, tissue adhesives or Onyx ® , or even a combination of these.…”