Carotid cavernous fistulas treated by endovascular covered stent grafts with follow-up results

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.

Neurovascular Interventions for Neurotrauma: From Treatment of Injured Vessels to Treatment of the Injured Brain?

Traumatic brain injury is often associated with a direct or secondary neurovascular pathology. In this review, we present recent advancements in endovascular neurosurgery that enable accurate and effective vessel reconstruction with emphasis on its role in early diagnosis, the expanding use of flow diversion in pseudoaneurysms, and traumatic arteriovenous fistulas. In addition, future directions in which catheter-based interventions could potentially affect traumatic brain injury are described: targeting blood brain barrier integrity using the advantages of intra-arterial drug delivery of blood brain barrier stabilizers to prevent secondary brain edema, exploring the impact of endovascular venous access as a means to modulate venous outflow in an attempt to reduce intracranial pressure and augment brain perfusion, applying selective intra-arterial hypothermia as a neuroprotection method mitigating some of the risks conferred by systemic cooling, trans-vessel wall delivery of regenerative therapy agents, and shifting attention using multimodal neuromonitoring to post-traumatic vasospasm to further characterize the role it plays in secondary brain injury. Thus, we believe that the potential of endovascular tools can be expanded because they enable access to the "highways" governing perfusion and flow and call for further research focused on exploring these routes because it may contribute to novel endovascular approaches currently used for treating injured vessels, harnessing them for treatment of the injured brain.

Endovascular Treatment of Traumatic Vascular Injuries in the Head and Neck Region

Background and Objectives: Traumatic vascular injuries of the head and neck pose significant treatment challenges due to the complex anatomy, diverse clinical presentation, and mostly emergent nature. Endovascular treatment increasingly complements traditional surgical approaches. This study aimed to report our 10-year experience in treating traumatic vascular injuries of the head and neck with endovascular therapy and to determine the effectiveness of endovascular treatment. Materials and Methods: A retrospective analysis of 21 patients treated for head and neck vascular injuries between May 2011 and April 2021 was performed. Patients' medical histories, clinical presentations, imaging findings, treatment materials, and clinical outcomes were reviewed. Treatments included stenting, coil embolization, and other endovascular techniques focused on hemostasis and preservation of the parent vessel. Results: The most common injuries involved the internal maxillary artery branches (n = 11), followed by the common or internal carotid artery (n = 6), vertebral artery (n = 3), and others. Endovascular treatment achieved successful hemostasis in all but one case. In five of six carotid artery injuries and two of three vertebral artery injuries, we achieved successful hemostasis while preserving the parent vessel using covered and bare stents, respectively. Conclusions: Endovascular therapy might be a useful treatment modality for traumatic vascular injuries in the head and neck region, offering efficacy, safety, and a minimally invasive approach.

[Endovascular Treatment for Head and Neck Trauma]

Trauma to the head and neck region can have serious consequences for vital organs such as the brain, and injuries to blood vessels can cause permanent neurological damage or even death. Thus, prompt treatment of head and neck vessels is crucial. Although the level of evidence is moderate, an increasing amount of research indicates that endovascular treatments can be a viable alternative to traditional surgery or medical management. Embolization or reconstructive endovascular procedures can significantly improve patient outcomes. This article provides an overview of various endovascular options available for specific clinical scenarios, along with examples of cases in which they were employed.

Use of coronary stent grafts for the treatment of high-flow carotid cavernous fistula

Carotid cavernous fistulas are abnormal communications between the carotid artery or its branches and the cavernous sinus. It can be traumatic or spontaneous. The widely accepted treatment is by detachable balloons. Advancements in the field of endovascular medicine made available other options for the treatment of this condition. Covered stents are widely available and offer preservation of the parent artery while occluding the fistula.

Contralateral traumatic carotid cavernous fistula after a craniomaxillofacial fracture

Introduction

Carotid-cavernous fistula is an abnormal communication between the internal carotid artery, the external carotid artery or any of their branches and the cavernous sinus. This condition may occur spontaneously or after craniofacial trauma; in this case the fistula takes place on the same side as the craniofacial fracture and becomes symptomatic within a few weeks. The diagnosis is clinical; it must be evoked before any post-traumatic proptosis. Treatment must be started quickly to avoid visual or even vital complications.

Case presentation

We report the case of a 19 years old male patient who was admitted to the maxillofacial surgery department for osteosynthesis of a fracture of the left orbital roof after a traffic accident. The three-month's examination noted a right pulsatile proptosis with redness and decrease of the visual acuity. The cerebral MRI was in favor of a right sided direct CCF, which was confirmed by the arteriographie. The patient responded very well to embolization.

Discussion

Craniofacial trauma is a major cause of carotid cavernous fistula. When a patient has ophthalmic manifestations of vascular complications, early detection of CCF is important for preserving visual acuity. The diagnosis is mainly clinical based on the ophthalmological symptoms. CT and MRI scans show the indirect signs of the fistula. There are several types of invasive and non-invasive treatments. The evolution of the fistula is generally favorable and recurrence is not very frequent.

Conclusion

This case report is a documentation on an exceptional case of posttraumatic direct CCF occurring on the contralateral side of the skull base fracture.

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Posttraumatic carotid-cavernous fistula in a rare complication of craniofacial trauma.

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Contralateral CCF to the fracture side is even more exceptional.

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CCF's complications can be both invalidating and life threatening.

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The prognosis depends on the etiology and the therapeutic delay.

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Before an exophthalmic and ocular redness, it is always necessary to think of a cavernous carotid fistula especially when there has been a recent trauma.

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.

First line Treatment of Traumatic Carotid Cavernous Fistulas Using Covered Stents at Level 1 Regional Trauma Center

Objective

The widely accepted treatment option of a traumatic carotid cavernous fistula (TCCF) has been detachable balloon or coils based fistula occlusion. Recently, covered stent implantation has been proving an excellent results. The purpose of this study is to investigate our experiences with first line choice of covered stent implantation for TCCF at level 1 regional trauma center.

Methods

From November 2004 to February 2020, 19 covered stents were used for treatment of 19 TCCF patients. Among them, 15 cases were first line treatment using covered stents. Clinical and angiographic data were retrospectively reviewed.

Results

Procedures were technically successful in all 15 cases (100%). Immediate angiographic results after procedure were total occlusion in 12 patients (80%). All patients except two expired patients had image follow-up (mean 15 months). Recurred symptomatic three patients underwent additional treatments and achieved complete occlusion. Mean clinical follow-up duration was 32 months and results were modified Rankin Scale 1–2 in five, 3–4 in five, and 5 in three patients.

Conclusion

The covered stent could be considered as fist line treatment option for treating TCCF patients especially in unstable vital sign. Larger samples and expanded follow-up are required to further develop their specifications and indications.

Management of injuries near the innominate artery bifurcation using an accurate kissing Viabahn stent technique

OBJECTIVE

To evaluate the feasibility, safety, and efficacy of an accurate kissing Viabahn stent technique to manage injuries near the innominate artery bifurcation.

METHODS

This retrospective study included patients with injuries near the innominate artery bifurcation who were treated with an accurate kissing Viabahn stent technique. Perioperative and follow-up data were extracted and analysed.

RESULTS

A total of 10 patients were included (mean age, 52.8 years; six male and four female patients) with injuries at the following sites: the distal end of the innominate artery (n = 2), the innominate artery bifurcation (n = 5), the root of the right common carotid artery (n = 2) and the origin of the right subclavian artery (n = 1). All were successfully treated with the accurate kissing Viabahn stent technique. During follow-up (mean duration, 16.8 months), there were no complications, such as right upper limb ischaemia, neurological dysfunction, stent occlusion or migration.

CONCLUSIONS

The accurate kissing Viabahn stent technique to manage injuries near the bifurcation of the innominate artery was safe and effective, with good perioperative and long-term follow-up results.

Usefulness of Stent-Assisted Coil Embolization of Direct Traumatic Carotid-Cavernous Fistulas: Report of Three Patients and Review of Other Treatment Methods

Objective

Direct traumatic carotid-cavernous fisulas (dtCCFs) exhibit a high blood flow velocity and are often difficult to be treated. We report three dtCCF cases in which disappearance of the dtCCF and preservation of the internal carotid artery (ICA) were achieved by stent-assisted coil embolization of the fistula. We report these cases and compare them with those previously reported using other treatments.

Case Presentations

In the first case, we performed coil embolization without stenting for the initial treatment. The cerebral venous reflux disappeared and the patient's symptoms were temporarily ameliorated. However, 5 months after treatment, an aneurysm-like finding around the fistula was noted on MRA. Additional coils and insertion of a neck-bridging stent were required to obliterate the dtCCF and the symptoms disappeared. In the second and third cases, we intended to use stents initially to achieve tight embolization of the fistulas, and obliteration was achieved.

Conclusion

Use of neck-bridging stenting for dtCCFs may be a reliable method to preserve the parent artery while achieving tight packing around the fistula.

Treatment of Carotid Cavernous Fistula Presenting with Contralateral Exophthalmos: Several Experiences of Graft Stent

Objective

Graft stent for carotid cavernous fistula (CCF) is known to be a useful treatment. Here, we report our experiences of treatment with graft stents for CCFs.

Case Presentations

From 2015 through 2018, six patients underwent graft stent placement for CCF occlusion. Clinical and angiographic data were retrospectively reviewed. Access and deployment of a graft stent was successful in all patients and complete occlusion immediately after the procedure or 3-month follow-up angiography.

Conclusion

Graft stents should be considered as an alternative option of treating CCFs and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.

Treatment of direct carotid-cavernous fistulas with flow diversion - does it work?

Direct carotid-cavernous fistulas (CCFs) are high flow lesions that can be challenging to treat. A number of recent reports suggest that flow diversion may be a viable treatment option. We present a case of a post-traumatic CCF successfully treated with flow diversion and provide a review of the literature. Our results suggest that flow diversion is a potentially effective treatment option for CCFs and is most successful when used as an adjunctive therapy.

Orbital apex disorders: Imaging findings and management

Orbital apex disorders include orbital apex syndrome, superior orbital fissure syndrome and cavernous sinus syndrome. These disorders result from various etiologies, including trauma, neoplastic, developmental, infectious, inflammatory as well as vascular causes. In the past, these have been described separately based on anatomical locations of disease process; however, these three disorders share similar causes, diagnostic evaluation and management strategies. The etiology is diverse and management is directed to the causative process. This imaging review summarizes the pertinent anatomy of the orbital apex and illustrates representative pathological processes that may affect this region. The purpose of this review is to provide an update on the current status of diagnostic imaging and management of patients with orbital apex disorders.

Reconstruction of the Internal Carotid Artery After Treatment of Complex Traumatic Direct Carotid-Cavernous Fistulas With the Willis Covered Stent

BACKGROUND:

Endovascular treatment of complex traumatic direct carotid-cavernous fistulas (TDCCFs) is a challenge.

OBJECTIVE:

To evaluate the long-term efficacy of the Willis covered stent in endovascular treatment of complex TDCCFs, focusing on reconstruction and preservation of the internal carotid artery.

METHODS:

During the past 8 years, 25 patients with 27 TDCCFs who previously had unsuccessful treatment of fistulas with detachable balloons received endovascular treatment with Willis covered stents. The efficacy, complications, in-stent stenosis, angiographic, and clinical follow-up results were evaluated retrospectively between 6 and 88 months (mean, 43.8 months) after the stent placement.

RESULTS:

The technical success rate of stenting placement was 100%. Forty-four Willis covered stents were implanted into the target artery of 27 TDCCFs. Complete exclusion was achieved in 16 patients with 17 TDCCFs immediately after the stent placement, with transient endoleaks in 10 TDCCFs. Redilation was performed in 6 TDCCFs, and additional stents were implanted in the other 4 TDCCFs for endoleak exclusion. The initial angiographic results showed complete exclusion of fistulas with preservation of the internal carotid artery in 24 patients with 26 TDCCFs. One patient in whom complete occlusion initially was achieved subsequently experienced a delayed endoleak, which required placement of an additional stent. The angiographic follow-up results (mean, 30.3 months) demonstrated complete exclusion in all 27 TDCCFs, with patency of internal carotid artery in 23 patients. The clinical follow-up demonstrated a full recovery in 23 patients and improvement in 2 patients.

CONCLUSION:

The use of Willis covered stents was confirmed to be effective, safe, and a curative approach for endovascular treatment of complex TDCCFs and internal carotid artery reconstruction.

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

OBJECTIVE

The combination of coils and Onyx for the treatment of carotid-cavernous fistulas (CCFs) is an interesting new development. The purpose of the current study is to evaluate our preliminary experience with the combined use of coils and Onyx for the treatment of traumatic CCFs.

METHODS

Between April 2009 and July 2014, 16 patients with 17 traumatic CCFs were embolized with the so-called 'armored concrete' treatment modality using coils, Onyx-18, and a non-detachable balloon via the transarterial approach. The outcomes were assessed both clinically and radiologically. Digital subtraction angiography (DSA) follow-up was performed 3 or 6 months after endovascular treatment while clinical follow-up was continued until December 2014.

RESULTS

Obliteration of the CCFs was obtained with patency of the parent artery in all 16 cases. Follow-up DSA demonstrated stable occlusion of all the fistulas. Symptoms related to the CCFs were either resolved immediately or gradually over 2 months. No worsening of the cranial neuropathies was observed during the follow-up period which averaged 32.6 months.

CONCLUSIONS

The 'armored concrete' treatment modality using coils, Onyx, and a non-detachable balloon promises to be a safe, economical, and effective alternative in the management of traumatic CCFs.

Recurrent Carotid Cavernous Fistula Originating from a Giant Cerebral Aneurysm after Placement of a Covered Stent

We report the case of a recurrent carotid cavernous fistula (CCF) originating from a giant cerebral aneurysm (GCA) after placement of a covered stent. A 47-year-old woman presented with sudden onset of severe headache, and left-sided exophthalmos and ptosis. Cerebral angiography revealed a CCF caused by rupture of a GCA in the cavernous segment of the left internal carotid artery. Two covered stents were placed at the neck of the aneurysm. The neurological symptoms improved at first, but were aggravated in the 6 months following the treatment. Contrast agent endoleak was seen in the distal area of the stent. Even though additional treatments were attempted via an endovascular approach, the CCF could not be cured. However, after trapping the aneurysm using coils and performing superficial temporal artery-middle cerebral artery bypass, the neurological symptoms improved. In cases of recurrent CCF originating from a GCA after placement of a covered stent, it is possible to treat the CCF by endovascular trapping and surgical bypass.

Orbital apex disorders: a case series

Orbital apex syndrome is an uncommon disorder characterized by ophthalmoplegia, proptosis, ptosis, hypoesthesia of the forehead, and vision loss. It may be classified as part of a group of orbital apex disorders that includes superior orbital fissure syndrome and cavernous sinus syndrome. Superior orbital fissure syndrome presents similarly to orbital apex syndrome without optic nerve impairment. Cavernous sinus syndrome includes hypoesthesia of the cheek and lower eyelid in addition to the signs seen in orbital apex syndrome. While historically described separately, these three disorders share similar causes, diagnostic course, and management strategies. The purpose of this study was to report three cases of orbital apex disorders treated recently and to review the literature related to these conditions. Inflammatory and vascular disorders, neoplasm, infection, and trauma are potential causes of orbital apex disorders. Management is directed at the causative process. The cases described represent a rare but important group of conditions seen by the maxillofacial surgeon. A review of the clinical presentation, etiology, and management of these conditions may prompt timely recognition and treatment.

Covered stents for the endovascular treatment of a direct carotid cavernous fistula : single center experiences with 10 cases

OBJECTIVE

Covered stent has been recently reported as an effective alternative treatment for direct carotid cavernous fistulas (DCCFs). The purpose of this study is to describe our experiences with the treatment of DCCF with covered stents and to evaluate whether a covered stent has a potential to be used as the first choice in selected cases.

METHODS

From February 2009 through July 2013, 10 patients underwent covered stent placement for a DCCF occlusion. Clinical and angiographic data were retrospectively reviewed.

RESULTS

Covered stent placement was performed for five patients primarily as the first choice and in the other five as an alternative option. Access and deployment of a covered stent was successful in all patients (100%) and total occlusion of the fistula was achieved in nine (90%). Complete occlusion immediately after the procedure was obtained in five patients (50%). Endoleak persisted in five patients and the fistulae were found to be completely occluded by one month control angiography in four. The other patient underwent additional coil embolization by a transvenous approach. Balloon inflation-related arterial dissection during the procedure was noted in two cases; healing was noted at follow-up angiography. One patient suffered an asymptomatic internal carotid artery occlusion noted seven months post-treatment.

CONCLUSION

Although endoleak is currently a common roadblock, our experience demonstrates that a covered stent has the potential to be used as the first choice in DCCF; this potential is likely to increase as experience with this device accumulates and the materials continue to improve.

Jostent covered stent placement for emergency reconstruction of a ruptured internal carotid artery during or after transsphenoidal surgery

OBJECT

Internal carotid artery (ICA) rupture during transsphenoidal surgery (TSS) is an extremely difficult complication to treat. This study aimed to evaluate the immediate and long-term outcomes of covered stent placement for emergency reconstruction of ruptured ICAs during or after TSS.

METHODS

Seven patients underwent covered stent placement for emergency reconstruction of a ruptured ICA during or after TSS. The safety and effectiveness of covered stent placement for emergency reconstruction of ruptured ICAs were retrospectively analyzed.

RESULTS

Pretreatment angiography showed active bleeding in 6 patients (5 intraoperative and 1 postoperative) and a pseudoaneurysm in 1 patient. Of the 6 patients with active bleeding, 5 were treated with a successive operation to control active bleeding. The other patient was treated just after cardiopulmonary resuscitation due to massive nasal bleeding 20 days after revision of TSS. All active bleeding was controlled immediately after covered stent insertion in these 6 patients. One patient showed a gap between the covered stent and ICA wall without active bleeding 30 minutes after glycoprotein IIb/IIIa inhibitor administration due to in-stent thrombosis. The gap was occluded with coil embolization after completion of the temporarily suspended TSS. The seventh patient, whose ICA tear was treated with surgical suture, underwent covered stent placement for a pseudoaneurysm detected on postoperative Day 2. During a mean follow-up period of 46 months (range 12-85 months), all patients had excellent outcomes (modified Rankin Scale score of 0). All the stented ICAs were patent on vascular imaging follow-up at a mean of 34 months (range 12-85 months).

CONCLUSIONS

Covered stents appear to be a safe and effective option for emergency reconstruction of ruptured ICAs during or after TSS.

Endovascular management of radiotherapy-induced injury to brachiocephalic artery using covered stents

Actinic vascular lesions tend to be stenotic-occlusive lesions. In this article, we present 2 exceptional cases of pseudoaneurysms caused by radionecrosis of the supra-aortic trunks. Both patients were treated by a retrograde carotid approach and deployment of a self-expanding covered stent. Proper exclusion of the pseudoaneurysm was attained in both cases; the first patient remained asymptomatic 12 months later; the second patient died of mediastinitis. Compared with conventional surgery, endovascular management is a viable, less invasive alternative in select patients, especially in life-threatening cases.

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient

INTRODUCTION

Traumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery.

CASE SUMMARY

We present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome.

DISCUSSION

Most of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review.

CONCLUSION

It is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.

Endovascular stent-graft treatment for a traumatic vertebrovertebral arteriovenous fistula with pseudoaneurysm

The rarely occurring vertebrovertebral arteriovenous fistula (VVAVF) is characterized by abnormal direct communications between the vertebral artery or its branches and the neighboring venous system. We present our experience using a stent graft to occlude a chronic, traumatic VVAVF. A 40-year-old woman with dizziness and loud bruits from the occiput underwent digital subtraction angiography (DSA), which revealed a VVAVF with pseudoaneurysm at the C5-C6 level, with retrograde flow from the right vertebral artery. A stent graft was placed across the fistula after balloon dilation. The fistula and pseudoaneurysm disappeared immediately. After 9 months, the patient remained asymptomatic with a patent stent.

Balloon-assisted coiling of the cavernous sinus to treat direct carotid cavernous fistula. A single center experience of 13 consecutive patients

This study evaluated clinical and neuroradiological results in 13 consecutive patients with spontaneous and traumatic direct carotid cavernous fistulas treated at our center between January 2006 and September 2012. All patients were treated by coiling of the cavernous sinus. Coiling was always performed while a semi-compliant non-detachable balloon was temporarily inflated in the internal carotid artery. This technique (balloon-assisted coiling) permitted a clear visualization of the fistula, facilitated coil positioning and protected the patency of the artery. All patients' clinical data and radiological examinations were reviewed; nine patients underwent radiological and clinical follow-up, with a mean duration of 3.8 years (range: six months-six years). Overall results at discharge showed a complete occlusion of the fistula in seven patients (7/13, 54%) and a resolution of symptoms in eight patients (8/12, 67%). Radiological follow-up showed complete occlusion of the fistula in all patients (9/9, 100%) and clinical follow-up showed a resolution of symptoms in eight patients (8/9, 89%) and persistent symptoms in one (1/9, 11%). No procedure-related complications occurred. Balloon-assisted coiling of the cavernous sinus for the treatment of direct carotid cavernous fistulas proved an effective and safe technique, both in angiographic and clinical terms, and may be considered a technical improvement.

Carotid Cavernous Fistulae Occurring After the Use of the Fogarty Catheter in Carotid Surgery

The Fogarty catheter represents a major advancement for the effective removal of distal thrombi during vascular surgery, including carotid endarterectomy (CEA). One complication related to its use is injury to the cavernous carotid artery with development of a carotid cavernous fistula (CCF). Including a recent case at our institution, 21 patients with a Fogarty-related CCF have been reported since 1967. We performed a detailed review of all Fogarty-related CCFs during the treatment of carotid occlusive disease. We suggest a management algorithm for post-CEA acute carotid occlusion.

Traumatic carotid-cavernous fistula presenting as massive epistaxis

Carotid-cavernous sinus fistulae (CCF) are a rare complication with the potential for great morbidity including intracranial hemorrhage, blindness, cranial nerve palsy and stroke. Traumatic CCF are the most common type of CCF. Here we discuss a patient who sustained blunt head trauma and had substantial epistaxis, requiring massive transfusion, intraoperatively due to unrecognized CCF.

Carotid-cavernous fistulas

Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.

Use of onyx for transarterial balloon-assisted embolization of traumatic carotid cavernous fistulas: a report of 23 cases

BACKGROUND AND PURPOSE

TCCFs are a common complication following craniofacial trauma and are usually treated by coils or detachable balloons. The use of the liquid embolic agent Onyx as the sole agent for the treatment of TCCFs has been rarely reported. Herein, we summarized the preliminary experience and effectiveness of treating TCCFs with Onyx in 23 patients.

MATERIALS AND METHODS

From the 36 type A CCFs treated in our department between September 2005 and March 2011, a total of 23 posttraumatic direct CCFs were treated by using Onyx only via transarterial approach.

RESULTS

Immediate postprocedural angiograms demonstrated complete occlusion in all patients. All the patients underwent a single procedure except 1 with bilateral TCCFs. Up to 24-month clinical and 3-month angiographic follow-ups revealed an ongoing complete occlusion without any complications.

CONCLUSIONS

In this series, the use of Onyx for the transarterial embolization of TCCFs was feasible and effective. Associated adverse events were rare.