Endovascular Graft-Stent Placement for Treatment of Traumatic Carotid Cavernous Fistulas

Abstract

J Korean Neurosurg Soc 46 : [572][573][574][575][576] 2009 Detachable balloon-based endovascular fistula occlusion is a widely accepted treatment for traumatic carotid cavernous fistulas (CCF). However, more recently coils have been used to obliterate the lesion, especially in case detachable balloon is not available. We failed balloon-assisted coil embolization for CCF because of large fistulas and herniation of coil loops into the parent artery. The authors describe our experiences of balloonexpandable graft-stents to treat CCF, and place emphasis on arterial wall reconstruction. Three traumatic CCF patients were treated using a graft-stent with/without coils, and underwent angiographic follow-up to evaluate the patency of the internal carotid artery (ICA). In all cases, symptoms related to CCF regressed after stent deployment and did not recur during follow-up. Follow-up angiography revealed good patency of the ICA in all patients. Graft-stents should be considered as an alternative means of treating CCF 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.

Endovascular Treatment of Posttraumatic Carotid‐Cavernous Fistulas and Pseudoaneurysms with Covered Stents

“…Furthermore, even with 100% CCF occlusion following initial treatment, a relatively high rate of pseudoaneurysm formation has been reported on long‐term follow‐up angiography . Therefore, some centers have been using covered stents for the treatment of TCCFs and pseudoaneurysms …”

“…In recent years, covered stents have been used to treat neurovascular pathologies such as aneurysms, pseudoaneurysms, dissections, and CCFs. On reviewing the major published English literature, as shown in Table , not more than 100 posttraumatic CCFs have been reported as successfully treated with covered stents. These reports mainly involved the balloon‐expandable coronary stent graft (JoMed and Jostent).…”

“…Although promising results have been achieved, the clinical use of covered stents for posttraumatic CCFs has generally been limited to selective cases without a tortuous ICA, due to the main drawback of a lack of longitudinal flexibility, which makes it difficult to navigate the graft stent into the lesions. To overcome this limitation, one must provide extra support to the stent by using a long sheath, a guide catheter, and a stiff exchange wire that contributes to straightening the vessel .…”

Cerebral Hemorrhage after Endovascular Treatment of Bilateral Traumatic Carotid Cavernous Fistulae with Covered Stents

“…But nowadays, other treatment options, such as transarterial and/or transvenous coil embolization and trapping of the ICA, are adopted on a case-by-case basis because detachable balloons are not always successful and not available everywhere 6,7,13,16,18) . Recently, covered stents have been emerged as a valid alternative to replace previous treatment methods 2,4,11) . However, the use of covered stents may involve some problems, for example, difficult navigation of the stent devices due to high stiffness, no availability of mounted covered stents >5 mm in diameter, and a risk of instent thrombosis or stenosis 2,4,15) .…”

“…Recently, covered stents have been emerged as a valid alternative to replace previous treatment methods 2,4,11) . However, the use of covered stents may involve some problems, for example, difficult navigation of the stent devices due to high stiffness, no availability of mounted covered stents >5 mm in diameter, and a risk of instent thrombosis or stenosis 2,4,15) . TCCF usually is single and unilateral, but unilateral double TCCFs and bilateral TCCFs are uncommon of one CCF may change the hemodynamics of contralateral TCCF, in other words, sudden blockage of the contralateral venous drainage through intercavernous sinus may make venous hypertension worsen; 2) compromised flow in the ICA after therapeutic occlusion may increase intravascular pressure on the contralateral side to expand the shunt, particularly patient revealed engorged superior ophthalmic vein, pointing to TCCF.…”