Transvenous Embolization of Carotid Cavernous Fistula through Inferior Petrosal Sinus with Detachable Coils and Ethylene Vinyl Alcohol Copolymer

Summary

The purpose of the article is to present our experience in endovascular treatment via the inferior petrosal sinus of the carotid cavernous fistula with detachable coils and ethylene-vinyl alcohol copolymer.

Abstract

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal branches of the external carotid artery (indirect fistula) and the cavernous sinus (CS). Trauma is the most common cause of CCF. The clinical presentation of CCF is closely related to the venous drainage pattern. Orbital and neuro-ophthalmological symptoms are the most common clinical presentation of CCF with drainage through the superior ophthalmic vein (SOV). Endovascular embolization by arterial or venous approaches is the most common management of CCF. Transvenous embolization using detachable coils and ethylene-vinyl alcohol copolymer (EVOH) is an alternative method for the treatment of CCF. Endovascular embolization offers different options to treat CCF by minimally invasive approach decreasing morbidity and residual fistulas. The purpose of this article is to report our treatment experiences via the inferior petrosal sinus (IPS), and immediate-term outcomes of endovascular embolization of CCF by using detachable coils and EVOH.

Introduction

Carotid cavernous fistula (CCF) is defined as abnormal arteriovenous communications between the internal carotid artery or meningeal branches of the external carotid artery and the cavernous sinus¹. CCF can be classified based on the etiology (traumatic or spontaneous), flow rate (high or low flow), or the angiographic composition (direct or indirect)^1,2. The clinical presentation of CCF is closely related to the venous drainage pattern: orbital and neuro-ophthalmological symptoms associated with drainage via the SOV, whereas neurological symptoms or intracranial hemorrhage related to l....

Protocol

The protocol has been approved by the local medical and ethics committees. All patients provided written informed consent.

1. Preoperative Preparation

1. Ensure the patients are diagnosed with CCF: All patients undergo digital subtraction angiography (DSA), routine bilateral internal and external carotid angiography, vertebral arteriography for assessment of feeding arteries, sizes, venous drainage patterns of CCFs, and carotid artery compression test with three-dimensional rotational.......

Discussion

Recently, endovascular treatment has become the most common therapy for CCFs. Successful treatment of CCFs is to occlude the abnormal shunts between the ICA or meningeal branches of the external carotid artery and the CS while keeping the ICA unobstructed. The treatment can be achieved with transarterial or transvenous approach to obliterate the affected side CS with coils or other embolic materials. Some patients with direct CCFs can be cured with the deployment of a covered stent across the fistula through ICA. The dis.......

Materials

Name	Company	Catalog Number	Comments
EV3 coil	Medtronic, Irvine, California, USA	material for endovascular treatment
MicroPlex coil	MicroVention, California, USA	material for endovascular treatment
EVOH	Medtronic, Irvine, California, USA	material for endovascular treatment
Echelon/microcatheter	Medtronic, Irvine, California, USA	interventional material
Envoy/guiding catheter	Johnson & Johnson Company,USA	interventional material
vascular sheath	Terumo Corporation, Tokyo, Japan	interventional material