J Cerebrovasc Endovasc Neurosurg.  2021 Mar;23(1):54-59. 10.7461/jcen.2021.E2020.05.002.

Is the retrograde access for endovascular treatment of a traumatic carotid cavernous fistula associated with dissection of the ipsilateral carotid possible?

• Pagiola I
• Amaral B
• Saito C
• Nalli D
• Junior HC
• Frudit M

• KMID: 2514339
• DOI: http://doi.org/10.7461/jcen.2021.E2020.05.002

Abstract

This is a case demonstrating a combined traumatic lesion of the internal carotid artery (dissection and a carotid cavernous fistula [CCF]) in a patient who was beaten during a robbery and, while trying to escape, was hit by a vehicle. Endovascular approach for the treatment was chosen using the retrograde access from the vertebral artery to the cavernous sinus by posterior communicating (Pcom) artery due to the occlusion of the ipsilateral internal carotid. Because the artery access by the internal carotid was impossible, retrograde approach by vertebral artery and Pcom artery was done to treat the direct CCF. A patient presented with left hemiplegia and proptosis, chemosis, right eye ptosis. Computed tomography (CT) and CT angiography revealed a CCF of the right carotid. An arterial retrograde endovascular approach by the vertebral artery was used for CCF occlusion with coils. We present a rare case of a combined traumatic cerebrovascular lesion, right carotid artery dissection and a right direct CCF treated by a retrograde endovascular approach by the vertebral artery through the Pcom artery to reach the fistula point and achieved a complete cure of the CCF.

Keyword

Carotid-cavernous sinus fistula, Carotid artery, Internal, Dissection, Endovascular procedures

Figure

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  Fig. 1. Right CCA DSA lateral view. (A) Early arterial phase of the right CCA. (B) Late arterial phase of the right CCA. CCA, common carotid artery; DSA, digital subtraction angiography.

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  Fig. 2. Right vertebral artery DSA. (A) Early arterial phase (frontal view) before treatment. (B) Late arterial phase (frontal view) before treatment. (C) Early arterial phase (lateral view) before treatment. (D) Late arterial phase (lateral view) before treatment. DSA, digital subtraction angiography.

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  Fig. 3. Right vertebral artery DSA during the treatment. (A) Right vertebral artery roadmap (frontal view) with the microcatheter navigation throw the Pcom artery to achieve the fistular point. (B) Right vertebral artery DSA (lateral view) after microcatheter navigation. Highlighted with dotted line: Unsubtraction image with the microcatheter position. (C) First coil deployment. (D) Second coil deployment. (E, F) Positioned the microcatheter into the fistula point and Coils was detached to occlude the fistula point and the ICA beyond the ophthalmic artery. DSA, digital subtraction angiography; ICA, internal carotid artery.

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  Fig. 4. Right vertebral artery DSA after treatment. (A) Early arterial phase of the right vertebral artery (frontal view) after endovascular treatment. (B) Late arterial phase of the right vertebral artery (frontal view) after endovascular treatment. (C) Early arterial phase (lateral view) after treatment. (D) Unsubtraction image of arterial phase (lateral view) after treatment. DSA, digital subtraction angiography.

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