Long-Term Outcomes of Endovascular Treatment of Indirect Carotid Cavernous Fistulae: Superior Efficacy, Safety, and Durability of Transvenous Coiling Over Other Techniques

Abstract

BACKGROUND Endovascular surgery is the first-line treatment for indirect cavernous carotid fistulae (CCFs). This study compares multiple treatment techniques. OBJECTIVE To compare endovascular techniques for indirect CCF treatment. METHODS Retrospective analysis was performed of prospectively maintained records at 4 centers, identifying patients undergoing indirect CCF embolization. Demographics, symptoms, and lesion characteristics were recorded. Medical records were reviewed for changes in symptoms, delayed complications, and angiographically proven recurrence. Univariate and multivariate analyses were performed to identify impacts of the above characteristics on outcomes. RESULTS Sufficient records were available for 267 patients treated between January 1987 and December 2016. Obliteration was achieved in 86.5% patients, occurring in 86.9% of exclusively transvenous treatments and 79.5% of other treatments. Obliteration rates were highest following transvenous embolization using coils compared to all other materials (likelihood ratio [LR] 5.0, P = .024). Complications were less common with coil embolization compared to other materials (LR 0.070, P < .001). Embolization with liquid embolics resulted in higher complication rates (LR 10.2, P = .002), although risk was reduced when used in conjunction with coils. Angiographically confirmed recurrence was more common following embolization with polyvinyl alcohol (LR 9.9, P = .004) and when multiple embolic agents were used (LR 6.6, P = .018). Delayed development of symptoms following embolization was less common following embolization with coils (LR 0.20, P = .030) and more common following embolization with liquids (LR 6.5, P = .014). CONCLUSION To treat indirect CCFs, transvenous coil embolization is the safest and most effective technique. Liquid embolics are less effective and have more complications and should be carefully considered only in extenuating circumstances.

Updates in the management of cranial dural arteriovenous fistula

“…Transvenous approach is preferred when a dAVF is supplied by small tortuous arteries excluding safe transarterial access to fistulous part, when dAVF is only supplied by branches directly from the ICA or vertebral artery, when dAVF is supplied by arteries with dangerous extracranial to intracranial anastomosis, or when the dAVF is supplied by nutrient arteries of cranial nerves 33 34. Similarly, a transvenous approach is the first line of treatment of an indirect CCF, where there is high probability of dangerous anastomosis, involvement of arteries supplying cranial nerves and very small feeding arteries to the fistula 34 35. Type I and II dAVFs of the hypoglossal canal are also the very good candidates for transvenous embolisation 36…”

Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

“…Feeders of CS-DAVFs are from abundant ECA and/or ICA branches, in which the middle meningeal artery (MMA), accessory meningeal artery, and ascending pharyngeal artery (APhA) are the most clinically significant branches [13][14][15][16]. These feeders may be bilateral in nearly 70% of cases [16,17]. Under normal circumstances, these small dural branches may not be visible on catheter angiography but become hypertrophic or enlarged when supplying CS-DAVFs [18].…”

“…In the high pressure gradient environment of CS-DAVFs, the arterialized veins reverse the direction of their normal inlet, and the drainers are highly variable [16]. Superior ophthalmic vein (SOV) drainage is a frequent finding that can be present in 88% of patients with CS-DAVFs, while the rate is only 42% with inferior petrous sinus (IPS) drainage and 34% with cortical venous drainage [27].…”

<p>Neuro-Endovascular Intervention in Traumatic Carotico-Cavernous Fistulae: A Single-Center Experience</p>

“…Coils have the advantages of quick movement, removal, exchange and recovery, and the catheter is easily transarterially or transvenously navigated to the cavernous sinus. 14,15 The fistula was conveniently connected by placing the coils near the fistula from the arterial side without falling into the parent artery. It has also been demonstrated for a long time as a safe and successful treatment that can lead to symptoms being relieved in many patients.…”