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

Treatment of Traumatic Direct Carotid-Cavernous Fistula with a BeGraft-Covered Stent

The widely accepted option for treating traumatic direct carotid-cavernous fistula (dCCF) has been endovascular treatment using detachable balloons, coils, or embolic agents. Covered stent deployment has been applied by a few operators and has shown promising results. This is a retrospective study on patients with dCCF treated by an endovascular approach using BeGraft, a covered stent. In 4 cases, this device was successfully deployed without any complications. Immediate complete occlusion was achieved in 3 patients (75%) after deployment of the covered stents. One patient required transvenous coiling for occlusion of the remaining endoleak. Follow-up imaging demonstrated 100% fistula occlusion with complete internal carotid artery patency. No early or late complications occurred following treatment. In conclusion, the BeGraft-covered stent could be a promising safe and effective alternative option for the endovascular treatment of dCCF.

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.

Application of the Willis Covered Stent in the Treatment of Complex Vascular Diseases of the Internal Carotid Artery and Vertebral Artery: A Retrospective Single-Center Experience

Objective

To retrospectively evaluate the efficacy and security of Willis covered stent (WCS) deployment for complex vascular diseases of the internal carotid (ICA) and vertebral (VA) arteries.

Methods

Retrospective analysis was performed on complex vascular disease patients (n=36) treated with WCSs at our center between March 2017 and December 2022, with a 3-36-months follow-up surveillance and digital subtraction angiography (DSA) examination.

Results

The WCSs were successfully deployed in all the patients. The 36 included lesions were carotid-cavernous sinus fistulas (CCFs; n=10) (27.8%), complex saccular aneurysms (n=10) (27.8%), traumatic pseudoaneurysms (n=7) (19.4%), blood blister-like aneurysms (BBAs; n=5) (13.9%), and iatrogenic carotid or vertebral artery ruptures (n=4) (11.1%). The WCS was released at the communicating segment (n=2) (5.6%), the ophthalmic segment (n=3) (8.3%), the clinoid and cavernous segment (n=28) (77.8%), the petrous segment (n=2) (5.6%) of ICA and the V3 segment (n=1) (2.8%) of VA. Postoperative DSA showed complete lesion occlusion in 26 patients (72.2%) who were immediately treated with WCSs, and endoleaks occurred in 3 patients (8.3%) (endoleaks resolved postadjustment in 7 patients (19.4%)). In patients (n=3) (8.3%) treated with double stents at the break of the ICA, the endoleak remained in 1 CCF patient (2.8%) during the 3-month follow-up, and the residual shunt disappeared after the second stent system was placed 3 months later. No aneurysm, bleeding or infarct recurrence reported, and only 1 patient (2.8%) had mild asymptomatic in-stent stenosis. Deaths and procedural complications did not occur during follow-up.

Conclusion

Treatment with a WCS for intracranial complex vascular diseases resulted in satisfactory clinical outcomes and appeared effective and safe. Controlled, multicenter, large sample sizes and longer follow-up periods studies are necessary.

Efficiency of endovascular management with a combination of Onyx and coils for direct and indirect carotid cavernous fistula treatment: experience of a single center

BACKGROUND

To evaluate the safety and efficacy of endovascular treatment with a combination of Onyx and coils for carotid cavernous fistulas (CCFs), and to characterize the factors associated with clinical and angiographic outcomes for direct and indirect CCFs.

METHODS

This retrospective study included 31 patients with CCF treated with an endovascular procedure between December 2017 and March 2022.

RESULTS

Direct and indirect CCFs were found in 14 (45.2%) and 17 (54.8%) cases, respectively. Direct CCFs included eleven traumatic carotid cavernous fistulas. The most common symptom on admission was chemosis, which was seen in 17 (54.8%) patients. Eight (25.7%) cases were treated by the transarterial approach. Fourteen (45.2%) cases were treated using the femoral vein-inferior petrosal sinus approach. Seven (22.6%) were treated by direct puncture of the superior ophthalmic vein. Two (6.5%) were treated by the femoral vein-facial vein approach. Immediate complete occlusion and follow-up rates were 93.5% and 96.7%, respectively. Twenty-nine (96.7%) patients experienced an improvement in their symptoms at clinical follow-up. Chemosis was significantly improved or resolved in 15 patients. Ophthalmoplegia was improved or resolved in 10 patients. Visual impairment was improved in 6 patients. Proptosis was improved or resolved in 5 patients. One case (3.2%) experienced procedure-related complication presented with transient oculomotor nerve palsy. In univariate subgroup analysis, use of balloon, treatment approach, and history of head trauma were significantly different between the direct and indirect CCF groups.

CONCLUSIONS

Endovascular treatment with a combination of Onyx and coils is a safe and effective therapy for CCFs. In this study, the transarterial approach was a favorable option for embolization of direct CCFs. In contrast, the transvenous approach may be the first choice of treatment for indirect CCFs.