Endovascular embolization of carotid-cavernous fistulas: A pioneering experience in Peru

Abstract

Background:Endovascular embolization represents the method of choice for the treatment of carotid-cavernous fistulas (CCFs).Methods:We report our experience using the endovascular technique in 24 patients harboring 25 CCFs treated between October 1994 and April 2010, with an emphasis on the role of detachable balloons for the treatment of direct CCFs.Results:Of the 16 patients who presented with direct CCFs (Barrow Type A CCFs) (age range, 7–62 years; mean age, 34.3 years), 14 were caused by traumatic injury and 2 by a ruptured internal carotid artery (ICA) aneurysm. Eight patients (age range, 32–71 years; mean age, 46.5 years) presented with nine indirect CCFs (Barrow Types B, C, and D). The clinical follow-up after endovascular treatment ranged from 2 to 108 months (mean, 35.2 months). In two cases (8%), the endovascular approach failed. Symptomatic complications related to the procedure occurred in three patients (12.5%): transient cranial nerve palsy in two patients and a permanent neurological deficit in one patient. Detachable balloons were used in 13 out of 16 (81.3%) direct CCFs and were associated with a cure rate of 92.3%. Overall, the angiographic cure rate was obtained in 22 out of 25 (88%) fistulas. Patients presenting with III nerve palsy improved gradually between 1 day and 6 months after treatment. Good clinical outcomes [modified Rankin scale (mRS) ≤ 2] were observed in 22 out of 24 (91.6%) patients at last follow-up.Conclusions:Endovascular treatment using detachable balloons still constitutes a safe and effective method to treat direct carotid-cavernous fistulas.

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

“…Serbinenko and, later, Debrun developed techniques for the endovascular obliteration of direct CCFs, preserving the lumen of the ICA. Most patients who are successfully treated using balloons and coils show postoperative ICA patency ranging from 59% to 88% 11…”

Endovascular Occlusion of Dural Cavernous Fistulas through a Superior Ophthalmic Vein Approach

“…The advantage of using coils lies in its radiopacity, easy use, controlled deployment, and possibility to be removed if the initial placement is not optimal 31 . Also, coils adopt the shape of the fistulous compartment and rarely migrate or experience deformation 31 .…”

“…is not exempt from complications such as transient compressive neuropathies or cranial nerve ischemia/infarction caused by post-embolization cavernous sinus thrombosis and penetration within arterial collaterals, respectively 31 . There is a need for larger series and follow-up data to determine if Onyx can be considered a definitive treatment for this type of lesion 31 .…”

Clinical Profile and Management Outcomes among Patients with Carotid-Cavernous Fistula

“…4 Common causes include blunt trauma, ruptured ICA aneurysm, Ehlers-Danlos Syndrome, and iatrogenic interventions. 5,6 Indirect CCFs are low-flow shunts with connections between the cavernous arterial branches of the ICA and/or the ECA and the cavernous sinus. Hypertension, Ehlers-Danlos Type IV, fibromuscular dysplasia, dissection of the ICA and a post-menopause state are known risk factors for indirect fistulas.…”