Application of the Willis Covered Stent in the Treatment of Carotid-Cavernous Fistula: A Single-Center Experience

Covered Stent Treatment for Direct Carotid-Cavernous Fistulas: A Meta-Analysis of Efficacy and Safety Outcomes

BACKGROUND

Direct carotid-cavernous fistulas (dCCFs) involve the abnormal shunting of blood between the internal carotid artery and the cavernous sinus. The use of covered stents (CSs) has been reported for the treatment of complex carotid artery lesions. However, the efficacy and safety of CS treatment for dCCFs remain controversial. Thus, we performed a systematic review and meta-analysis to evaluate these efficacy and safety endpoints.

METHODS

A systematic literature review was performed by comprehensively searching the Medline, Embase, and Web of Science databases to identify studies that were related to CS treatment for dCCFs. Then, a meta-analysis was conducted to pool the efficacy and safety outcomes from these studies based on perioperative and follow-up data.

RESULTS

Fourteen noncomparative studies enrolling 156 patients with 160 dCCFs met the inclusion criteria. When analyzing perioperative outcomes, the technical success rate was 98.5% [95% confidence interval (CI), 0.948; 1.000], and the immediate complete occlusion rate was 90.9% (95% CI, 0.862; 0.959). Vasospasm and dissection occurred in 32.2% (95% CI, 0.238; 0.463) and 0.1% (95% CI, 0.000; 0.012) of patients, respectively. The in-stent acute thrombus formation rate was 0.1% (95% CI, 0.000; 0.013). Postoperatively, the mortality rate was 0.1% (95% CI, 0.000; 0.013). Based on available follow-up data, the final complete occlusion and parent artery stenosis rates were 99.3% (95% CI, 0.959; 1.000) and 18.6% (95% CI, 0.125; 0.277), respectively.

CONCLUSIONS

CS placement can be used to safely and effectively treat dCCFs. These results provide a reference for future clinical trials.

The Appearance of Middle Meningeal Artery Fistulae After Willis Covered Stent for Traumatic Carotid-cavernous Fistulae: Two Case Reports

INTRODUCTION

Carotid cavernous fistulae (CCF) are rare, and they occur when there is a communication between the internal carotid artery (ICA) and cavernous sinus. These lesions are associated with blunt or penetrating traumatic injuries of the carotid arteries. We present the first cases of cavernous dural arteriovenous fistulae (cDAVF) in the middle meningeal artery (MMA) after the treatment of direct CCF in the ICA with Willis-covered stents (WCSs).

CASE PRESENTATION

Our patients comprised 22 and 50-year-old males with histories of head injuries months before admission at our facility. In both patients above, cerebral angiography revealed fistulae in the right ICA and left ICA, respectively. They were treated with WCSs via the trans-artery endovascular route. In both cases, the treatments were not in the way attempted via the MMA. Subsequently, they developed cDAVF in the middle meningeal artery (MMA), which were treated with Onyx Liquid Embolic System (Onyx HD-500) (Covidien / ev3 Neurovascular) and conservatively, respectively.

CONCLUSION

These are the first cases in whom WCSs for the management of direct CCF resulted in cDAVF at the MMA. The WCSs inside the ICA could have resulted in the cDAVF via unknown mechanisms but not iatrogenic.

Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas

Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.

Endovascular Treatment of Complex Vascular Diseases of the Internal Carotid Artery Using the Willis Covered Stent: Preliminary Experience and Technical Considerations

Purpose: The Willis covered stent (WCS) is used to treat complex vascular diseases of the internal carotid artery; however, its performance requires further investigation. This study aimed to present our single-center clinical results and experience of endovascular repair of complex vascular diseases of the internal carotid artery using the WCS.

Methods: Patients who presented with complex vascular diseases of the internal carotid artery and who were treated with the WCS from December 2013 to September 2018 were retrospectively reviewed. Procedural results, perioperative complications, incidence of endoleak, and follow-up outcomes were analyzed.

Results: Sixty-five patients were enrolled. A total of 25 large aneurysms, 10 pseudoaneurysms, 14 blood blister-like aneurysms, 11 carotid–cavernous fistulas, and 5 surgical injuries were assessed. WCS placement was successful in all patients. Immediate angiography showed that complete repair of the target artery was achieved in 56 patients (86.2%). Endoleak was observed in nine patients, including seven type I endoleaks and two type II endoleaks. Occlusion of a side-branch vessel occurred in four patients. Acute in-stent thrombosis occurred in one patient. No ischemic or hemorrhagic events or other complications developed during the perioperative and follow-up periods. Angiographic follow-up (mean duration, 12 ± 3.29 months) was performed in 60 patients and showed complete target artery repair in 58 patients, and asymptomatic mild to moderate in-stent stenosis was observed in four patients. Slight endoleak persisted in two patients without enlargement or rupture of the residual lumen.

Conclusion: WCS implantation is safe, feasible, and efficacious for endovascular repair in patients with complex vascular diseases of the internal carotid artery, showing excellent short-term target artery patency and clinical outcomes.

Clinical classification and individualized design for the treatment of basicranial artery injuries

This study aims to explore the principles of clinical classification and individualized treatment of basicranial artery injuries based on its anatomical correlation.The data of 172 patients with various types of basicranial artery injuries were retrospectively analyzed. Among these patients, 128 patients were male and 44 patients were female, and the average age of these patients was 28.3 years old. All patients underwent computed tomography, some patients underwent computed tomography angiography or magnetic resonance angiography, and all the diagnoses were confirmed by digital subtraction angiography (DSA). According to anatomical correlation, the injuries were classified into 5 types: vascular wall injury (type I), intradural injury (type II), epidural injury (type III), sinus injury (type IV), and skull base bone injury (type V). Individualized treatment was adopted based on the different types and characteristics of injuries.The percentages of basicranial artery injuries were as follows: type I, 4.6%; type II, 5.8%; type III, 3.5%; type IV, 77.9%; and type V, 8.1%. All 172 patients underwent DSA to demonstrate the classification. The lesion elimination rate revealed by DSA was 99.4% immediately after the operation, 98.3% at 1 week after the operation, and 98.8% at 3 months after the operation. The follow-up after 6 months revealed that the percentage of patients in whom clinical symptoms or signs completely disappeared was 97.7%, the percentage of patients with limited eye movement or visual impairment was 1.2%, and the percentage of patients with mild limb dysfunction was 0.6%.Basicranial artery injuries can be classified into 5 types. Individualized design of embolization therapy based on different characteristics might be applicable for basicranial artery injuries treatment.