J Korean Neurosurg Soc.  2015 Jan;57(1):12-18. 10.3340/jkns.2015.57.1.12.

Covered Stents for the Endovascular Treatment of a Direct Carotid Cavernous Fistula : Single Center Experiences with 10 Cases

• Li K
• Cho YD
• Kim KM
• Kang HS
• Kim JE
• Han MH

• KMID: 2067085
• DOI: http://doi.org/10.3340/jkns.2015.57.1.12

Abstract

OBJECTIVE
Covered stent has been recently reported as an effective alternative treatment for direct carotid cavernous fistulas (DCCFs). The purpose of this study is to describe our experiences with the treatment of DCCF with covered stents and to evaluate whether a covered stent has a potential to be used as the first choice in selected cases.
METHODS
From February 2009 through July 2013, 10 patients underwent covered stent placement for a DCCF occlusion. Clinical and angiographic data were retrospectively reviewed.
RESULTS
Covered stent placement was performed for five patients primarily as the first choice and in the other five as an alternative option. Access and deployment of a covered stent was successful in all patients (100%) and total occlusion of the fistula was achieved in nine (90%). Complete occlusion immediately after the procedure was obtained in five patients (50%). Endoleak persisted in five patients and the fistulae were found to be completely occluded by one month control angiography in four. The other patient underwent additional coil embolization by a transvenous approach. Balloon inflation-related arterial dissection during the procedure was noted in two cases; healing was noted at follow-up angiography. One patient suffered an asymptomatic internal carotid artery occlusion noted seven months post-treatment.
CONCLUSION
Although endoleak is currently a common roadblock, our experience demonstrates that a covered stent has the potential to be used as the first choice in DCCF; this potential is likely to increase as experience with this device accumulates and the materials continue to improve.

Keyword

Carotid cavernous fistula; Covered stent; Endovascular treatment

MeSH Terms

Angiography
Carotid Artery, Internal
Embolization, Therapeutic
Endoleak
Fistula*
Follow-Up Studies
Humans
Retrospective Studies
Stents*

Figure

• 

  Fig. 1 A : Left ICA angiography shows that steal of the flow toward the cavernous sinus and primary flow drained into ophthalmic vein, superior petrosal sinus, and inferior petrosal sinus. B : Left ICA angiography performed under ipsilateral carotid compression shows that the fistula was located at the genu portion of the cavernous ICA. C : Coronal source image of 3D rotational angiography shows the connection between the ICA and the cavernous sinus. D : Repeated balloon inflation with higher pressure to augment apposition of the stent to the vessel wall was performed. E : Final angiography shows that the fistula with decreased shunt flow persisted and balloon-induced arterial dissection was observed. F : The fistula was completely occluded and arterial dissection was stable at one month follow-up angiography. Minimal stenosis at the proximal end of stent was detected. ICA : internal carotid artery, 3D : three-dimensional.

• 

  Fig. 2 A : Right ICA angiography shows that steal of the flow toward the cavernous sinus and intracranial flow was diminished. B : Left ICA angiography performed under ipsilateral carotid compression shows that the fistula was located at the vertical portion of the cavernous ICA. C : After placement of the covered stent at the fistula location, initial balloon inflation was performed to detach the covered stent from the balloon. D : High shunt flow remained; however, velocity was lessened. E : Repeated balloon inflation with higher pressure was carried out. F : The endoleak with more decreased shunt flow remained. G : Additional balloon inflation with a larger sized-balloon was performed. H : The fistula was totally occluded. ICA : internal carotid artery.

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