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

Transradial access embolization of carotid-cavernous fistulae: Case report

Carotid-Cavernous sinus fistula (CCF) represents a misdiagnosed condition with potential repercussion in functional, neurological, and social roles of patients with this disease. Earlier reports remark on the efficiency and safety of endovascular therapy with resolution of the symptoms were performed appropriately. We present a case of a male patient from a developing country, with gunshot wound head trauma history and short-term progressive functional and neurological impairment in the presence of intracranial hypertension and ocular symptoms who developed a large CFF, subsequently treated by transradial access embolization. We aim to describe the real-world experience in diagnosis and treatment of CCFs, emphasizing on the scope and outcomes of the endovascular treatment. This case supports worldwide experience, positioning endovascular therapy as an effective strategy in the resolution of CFFs, and the relevance of suspecting this disease in the presence of typical symptoms, even if they are rapidly progressive.

Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience

BACKGROUND

While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear.

METHODS

A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis.

RESULTS

An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333).

CONCLUSION

FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.

Embolization of carotid-cavernous fistulas: A technical note on simultaneous balloon protection of the internal carotid artery

A carotid-cavernous fistula (CCF) is an abnormal connection between the carotid circulation and the cavernous sinus. Treatment of CCFs often consists of obliteration of the fistula by a transarterial or transvenous endovascular approach using embolic agents. However, fistula embolization is often halted due to the potential embolic complications that may arise from the retrograde flow of the embolic agents into the arterial circulation, which often leads to the development of fistula recurrence. Moreover, retreatment of a CCF recurrence is challenging and more complex approaches may be required. In this technical note, we describe our experience with CCF embolization in 25 patients treated at a single center. We utilized a transvenous approach for CCF embolization with simultaneous balloon occlusion of the internal carotid artery during the infusion of the embolic material into the fistula. In our series, this simultaneous protection of the internal carotid artery showed to be a safe technique to prevent embolic complications and to achieve successful obliteration of the fistula. On follow-up, 2 cases presented a recurrence, one due to technical difficulties and the other related to an undetected vascular injury. In conclusion, this technique provides a safe approach in the treatment of CCFs by decreasing the risk of embolic complications and increasing the effectiveness of the embolic agents in accomplishing the obliteration of the CCF.

Flow diverters as a scaffold for treating direct carotid cavernous fistulas

Background

Direct carotid–cavernous sinus fistulas (dCCFs) are high flow arteriovenous shunts between the internal carotid artery and the cavernous sinus. Recently, we have used the pipeline embolization device (PED) to treat dCCFs.

Methods

We describe our experience treating patients with dCCFs in whom the PED was placed as the primary treatment modality.

Results

Five patients with dCCFs were treated with PEDs deployed in the ipsilateral internal carotid artery spanning the fistula. All patients also underwent either adjunctive transvenous or transarterial embolization. The PED served both as the primary treatment modality and as a scaffold that facilitated safe and efficacious transvenous embolysate administration by altering the flow dynamics through the fistula and providing a physical barrier that protected the internal carotid artery. No intraoperative or perioperative complications occurred. One of the five patients exhibited complete angiographic resolution of the fistula immediately after the procedure. The remaining four patients experienced complete obliteration of the fistula without additional treatment, which suggests that the PED induced alteration promoted thrombosis of the fistula. Therefore, 100% of patients in this series exhibited complete and durable obliteration of the fistula and complete resolution of symptoms following treatment.

Conclusions

We believe that use of the PED to treat dCCFs may be a safe and efficacious strategy that facilitates parent vessel protection during transvenous embolization. Furthermore, the flow alterations induced by the PED may promote thrombosis of incompletely occluded fistulas. This is the largest reported series of non-iatrogenic dCCFs treated with use of the PED as the primary initial treatment strategy.

Post-traumatic carotid-cavernous fistula with bilateral proptosis simulating cavernous sinus thrombosis

A 48-year-old woman presented with bilateral non-pulsatile proptosis and ophthalmoplegia after 3 days following blunt orbital trauma. It was associated with fever, malaise and loss of vision in right eye. She was provisionally diagnosed with cavernous sinus thrombosis and was treated with intravenous antibiotics with no improvement. A subtle bruit was present on examination, and digital subtraction angiography revealed a right direct (type A) carotid-cavernous fistula (CCF). The patient underwent right coil embolisation of direct CCF. On follow-up at 4 months, her proptosis resolved completely and extraocular movements improved.

Superior ophthalmic vein and ophthalmic artery in immediate evaluation after endovascular treatment of carotid-cavernous fistulas

Purpose

To validate superior ophthalmic vein (SOV) and ophthalmic artery (OA) usefulness in immediate evaluation of new endovascular approaches to treat carotid-cavernous fistulas (CCFs).

Material and methods

A retrospective review of 597 intracerebral malformation embolisations yielded 40 embolisations of CCF in the treatment of 18 patients. Two interventional radiologists performed detailed radiological angiographic assessments.

Results

Mean age at initial admission was 58.9 years (SD 18.5 years, range 24-85 years). Patients presented with: chemosis (50%), ocular bruit (50%), exophthalmos (61%), diminished visual acuity (77.8%), headache (16.7%), and intracerebral haemorrhage (5.55%), and 5.55% were asymptomatic. Unilateral fistulas (10-55.5%) showed more diversified venous drainage pattern than bilateral ones (8-44.4%). There were statistically significant differences in post-traumatic and spontaneous CCF regarding age (p = 0.036), type of fistula (p = 0.0008), and presence of pseudoaneurysm (p = 0.036). 77.8% of patients had increased ipsilateral SOV diameter. SOV enlargement was not associated with type of fistula, history of trauma, or degree of exophthalmos. Ipsilateral ophthalmic artery was visible in all patients on both pre- and postprocedural angiography on lateral projection. Pre- and post-procedural SOV diameter was significantly different. Internal carotid artery patency was 100%, while the overall final angiographic or clinical success was 85.7%. We had three cases of peri-procedural complications.

Conclusions

We reported changeable dynamics of SOV and OA after endovascular treatment of CCFs and proved the feasibility of coils and Onyx-18 in the treatment thereof.

Combined use of coils and Onyx for transcatheter closure of coronary artery fistulae

AIMS

The aim of this study was to evaluate the safety and efficacy of combined endovascular coiling and Onyx embolisation in patients with a coronary artery fistula (CAF).

METHODS AND RESULTS

Between September 2014 and September 2016, 26 patients with CAFs were enrolled in our study for attempted combined therapy using coils and Onyx. The mean age of patients was 64.0±9.5 years (range, 44-78 years). CAFs were large in 10 and medium in 16 patients. The mean number of coils used was 3.1±1.2 (range, two to six), and the average volume of Onyx was 0.4±0.1 ml (range, 0.2-0.6 ml). Immediate post-embolisation angiography demonstrated that complete occlusion was achieved in 23 patients (88.5%) and a small residual fistula was achieved in three patients (11.5%). Follow-up imaging (median, 11.5 months; range, nine to 20) revealed stable occlusion of CAF in 21 cases (80.8%), trivial recanalisation in four cases (15.4%), and large recanalisation in only one case (3.8%). Re-closure was performed in the patient with large recanalisation. During the follow-up period, no deaths, severe procedure-related complications, or new symptoms occurred.

CONCLUSIONS

In selected patients with CAF, transcatheter embolisation in combined therapy using coils and Onyx appears to be a valid option, providing a high success rate and low rate of recanalisation.

Spontaneous Bilateral Carotid-Cavernous Fistulas Secondary to Cavernous Sinus Thrombosis

Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. We review the literature and discuss the pathophysiology, symptomatology, management, and treatment of bilateral carotid cavernous fistulas. Within our own cases, treatment of the patients was varied. The patient in case 1 was successfully treated with endovascular therapy after a failed trial of anticoagulation. The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.

Bilateral carotid cavernous sinus fistula: a case report and review of the literature

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. They are commonly classified based on hemodynamics, etiology or anatomically. Hemodynamic classification refers to whether the fistula is high or low flow. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of aneurysm or medical conditions predisposing to arterial wall defects. Bilateral carotid cavernous fistulas are rare. We present a case of bilateral CCF secondary to trauma. Ophthalmology was urgently consulted to assess the patient in the intensive care unit (ICU) for red eye. The patient was found to have decreased vision, increased intraocular pressure, an afferent pupillary defect, proptosis, chemosis, and ophthalmoplegia. Subsequent neuro-imaging confirmed a bilateral CCF. The patient underwent two endovascular embolization procedures. Trauma is the most common cause of CCF and accounts for up to 75% of cases. Most common signs of CCF depend on whether it is high or low flow. High-flow CCF may present with chemosis, proptosis, cranial nerve palsy, increased intraocular pressure, diplopia, and decreased vision. Cerebral angiography is the gold standard diagnostic modality. First-line treatment consists of endovascular embolization with either a metallic coil, endovascular balloon or embolic agent. It is unclear in the literature if bilateral cases are more difficult to treat or have a different prognosis. Our patient required two endovascular procedures suggesting that endovascular intervention may have reduced efficacy in bilateral cases.

A brief history of carotid-cavernous fistula

Carotid-cavernous fistula was one of the first intracranial vascular lesions to be recognized. This paper focuses on the historical progression of our understanding of the condition and its symptomatology-from the initial hypothesis of ophthalmic artery aneurysm as the cause of pulsating exophthalmos to the recognition and acceptance of fistulas between the carotid arterial system and cavernous sinus as the true etiology. The authors also discuss the advancements in treatment from Benjamin Travers' early common carotid ligation and wooden compression methods to today's endovascular approaches.

Advances in the endovascular treatment of direct carotid-cavernous fistulas

SUMMARY Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus. They are considered direct when there is a direct connection between the internal carotid artery and the cavernous sinus. These cases are generally traumatic. Direct CCFs are high-flow lesions, possibly related to intracranial bleeding, visual loss, corneal exposure or even fatal epistaxis. Treatment of such lesions is, thus, always recommended. The ideal treatment for direct CCF is to exclude the fistula from circulation, preserving the carotid flow. This can be attained using diverse endovascular techniques. The objective of the present article is to review the current techniques for treatment of direct CCFs, with special attention to the currently available endovascular treatment options.

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.

Traumatic carotid-cavernous fistula in a multiple facial fractures patient: case report and literature review

Carotid-cavernous fistula (CCF) is a pathologic communication between internal carotid artery (ICA) and cavernous sinus (CS). CCF occurs most commonly in association with craniofacial trauma. Traumatic CCFs are very rare, occurring in 0.17-0.27% of craniomaxillofacial trauma cases. We present a case of the patient treated for multiple facial fractures, who developed symptoms of CCF with several days latency and was successfully treated by endovascular occlusion of ICA. Anatomy of CS, pathophysiology of CCFs and treatment options are concisely reviewed.

Endovascular treatment in an unusual case of direct carotid cavernous fistula

We describe a unique and unusual case of post-traumatic direct carotid cavernous fistula (CCF) with occluded proximal internal carotid artery and CCF filling from the contralateral side with retrograde cortical venous reflux. A male patient presented with intracranial haemorrhage due to cortical venous reflux. He was treated endovascularly through a contralateral approach by coiling the cavernous sinus and occluding the distal internal carotid artery at the fistulous site with glue.

Transarterial treatment of direct carotico-cavernous fistulas with coils and Onyx

INTRODUCTION

The purpose of this study was to evaluate the role of combination of liquid embolic agent ethylene vinyl alcohol copolymer (Onyx) and detachable coils in the treatment of direct carotico-cavernous fistulas (CCFs).

METHODS

We prospectively collected clinical and radiological data of all patients who underwent embolization of direct CCFs at our institution over a period of 21 months. The clinical parameters, angioarchitecture, presence of cortical venous reflux, volume of Onyx used, number of coils used, extent of embolization and complications were recorded.

RESULTS

A total of 21 consecutive patients (18 men and 3 women, 14 to 48 years) with direct CCF underwent embolization with a combination of coils and Onyx. Embolization was done through the arterial route in all cases. Complete obliteration of the fistula was achieved in 19 of 21 cases. Cast embolization in middle cerebral artery occurred in one patient; however, the cast was completely retrieved with Solitaire device, and the patient did not have any neurological deficit. All completely treated patients reported relief of symptoms at varying intervals. At 6-month follow-up, none of the patients with complete occlusion of the fistula showed any recurrence.

CONCLUSION

The adjuvant use of Onyx with detachable coils in direct CCF through the arterial route is a safe and effective method for embolization with immediate and complete occlusion of the fistula. To the best of our knowledge, this is the first case series of demonstration of arterial use of Onyx with coils in the treatment of direct CCFs.