Treatment of carotid cavernous sinus fistulas with flow diverters. A case report and systematic review

Abstract

Introduction Carotid cavernous fistulas (CCFs) are rare, usually follow head trauma or aneurysmal rupture. Recent treatment options include endovascular techniques such as flow diversion devices (FDDs). Objective To present our case treated with FDD application with transarterial cavernous-sinus coiling and present a systematic review on the use and effectiveness of FDDs in CCF treatment. Materials and methods We present our case of CCF treatment with FDD. A search was also conducted in PubMed, EMBASE and Cochrane until November 2020. Reference lists were also cross-checked. Results Including our case, thirty-eight patients were identified with a CCF that was treated with FDDs in sixteen studies. Twenty-two patients were females, nine were males and the rest unidentified. The mean age was 52,6 years (range 17–86, SD± 19.28). Thirty-six patients suffered from direct and two from indirect CCFs. Single FDD was used in four cases, single FDD with embolic materials in eleven cases, multiple overlapping FDDs were used in six cases and multiple overlapping FDDs with embolic materials were used in seventeen cases. Thirty-five patients (92,1%) had clinical improvement, immediate angiographic occlusion was seen in 44,7% of the cases, while long-term occlusion rate was 100% but with variable follow-up periods. One patient (2,6%) presented with a neurological deficit related to FDD deployment. Conclusion Targeted treatment of CCFs with single or overlapping FDDs with or without adjunct embolic agents offers a high success rate, both clinically and long-term angiographically compared to other endovascular methods alone. However, further research with multi-center prospective trials is warranted.

Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

“…[18] In fact, flow diverters are designed with specific properties and their composition enables to preserve side arterial branches from occlusion. [18] e time required for achieving a fistula occlusion represents a disadvantage in preventing a rapid symptoms improvement after treatment. As regards to indirect fistulas, Castaño et al reported two cases of Barrow B-type of CCFs successfully treated with flow diverter stent in the left ICA in both cases.…”

“…The goal of the treatment should be the occlusion of the fistula site or at least the reduction to minimum of the residual arterial blood flow into the venous system while preserving the patency of ICA and its arterial branches. [ 18 , 19 ] Therapeutic approaches for CCFs followed the same transition through technological development. Historically, traditional maneuvers included manual compression of the CCA and jugular vein, and external ocular compression of the angular vein with or without carotid compression, with a rate of complete occlusion around 30%.…”

“…[ 4 , 8 , 11 , 17 ] Moreover, a combined approach using flow diverters with or without adjunct embolizing materials could be considered. [ 18 ] Usually, the transarterial approach is used, although in patients with tortuous or arteriosclerotic arteries reaching the fistula site may be extremely challenging; the risk of major complications such as migration of embolic agents into the cerebral circulation should not be forgotten. [ 4 , 8 ] On the other hand, transvenous approaches were proved to be a viable option with low risk and 90% of success rate, together with higher obliteration rate.…”

Failure of tandem flow diversion for intracranial aneurysms: Literature review and illustrative case

“…FDDs are becoming more important in aneurysmal treatment due to the significant intraoperative complications associated with open surgical approaches, the shallow nature, the shape of the aneurysms, and the natural tortuosity in some vessels such as the ICA, which renders stent-assisted coiling ineffective. [1,17] FDDs are new-generation stents used primarily in large and giant aneurysms, wide-necked, and recurrent aneurysms. [14] ey are used for saccular, fusiform, and blister-type ruptured aneurysms.…”

“…FDDs are becoming more important in aneurysmal treatment due to the significant intraoperative complications associated with open surgical approaches, the shallow nature, the shape of the aneurysms, and the natural tortuosity in some vessels such as the ICA, which renders stent-assisted coiling ineffective. [ 1 , 17 ]…”