J Korean Neurosurg Soc.  2021 Sep;64(5):818-826. 10.3340/jkns.2020.0345.

First line Treatment of Traumatic Carotid Cavernous Fistulas Using Covered Stents at Level 1 Regional Trauma Center

• Jeong SH
• Lee JH
• Choi HJ
• Kim BC
• Yu SH
• Lee JI

• KMID: 2519709
• DOI: http://doi.org/10.3340/jkns.2020.0345

Abstract

Objective
: The widely accepted treatment option of a traumatic carotid cavernous fistula (TCCF) has been detachable balloon or coils based fistula occlusion. Recently, covered stent implantation has been proving an excellent results. The purpose of this study is to investigate our experiences with first line choice of covered stent implantation for TCCF at level 1 regional trauma center.
Methods
: From November 2004 to February 2020, 19 covered stents were used for treatment of 19 TCCF patients. Among them, 15 cases were first line treatment using covered stents. Clinical and angiographic data were retrospectively reviewed.
Results
: Procedures were technically successful in all 15 cases (100%). Immediate angiographic results after procedure were total occlusion in 12 patients (80%). All patients except two expired patients had image follow-up (mean 15 months). Recurred symptomatic three patients underwent additional treatments and achieved complete occlusion. Mean clinical follow-up duration was 32 months and results were modified Rankin Scale 1–2 in five, 3–4 in five, and 5 in three patients.
Conclusion
: The covered stent could be considered as fist line treatment option for treating TCCF patients especially in unstable vital sign. Larger samples and expanded follow-up are required to further develop their specifications and indications.

Keyword

Traumatic carotid cavernous sinus fistula; Covered stent; Treatment

Figure

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  Fig. 1. An 18-year-old man with left-sided exophthalmos and ptosis in 48 days after motor cycle accident. A : Lateral digital subtraction image of left ICA showing the presence of a TCCF draining via the superior ophthalmic vein, pterygoid plexus, and petrosal sinuses. B : Lateral angiography after distal access guiding catheter (white arrow) delivery to anterior genu of cavernous ICA. Black arrow demonstrated rupture site of ICA. C : Lateral radiography demonstrating deployment of covered stent and white arrow indicated proximal end of the stent. D : Immediate post-procedural angiography confirmed endoleak at proximal end of the stent due to size mismatch. Black arrow confirmed endoleak point. E : Lateral radiography showing additional overlapping covered stent (white arrow) using telescoping technique. F : Final angiogram demonstrating complete occlusion of TCCF. ICA : internal carotid artery, TCCF : traumatic carotid cavernous fistula.

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  Fig. 2. A 54-year-old female with life threatening epistaxis after transsphenoidal pituitary adenoma surgery. A : Lateral angiogram of left ICA demonstrating iatrogenic TCCF with pseudoaneurysm formation (black arrow) at horizontal segment of cavernous ICA. B and C : After the covered stent was deployed (white arrow), complete occlusion of CCF was confirmed. D : Oblique delayed angiography after covered stent deployment showed ICA stenosis distal to the stent, which confirmed vasospasm (black arrow). E : Recurrent epistaxis developed 2 days after covered stent treatment and angiography confirmed endoleak at distal end of the stent (black arrow). F : After repeated balloon angioplasty (black arrowhead), angiography showed a decrease of fistula flow but still persisted. G and H : Microcatheter (white arrow) selection through fistula point at distal end of the stent and additional stent assisted coiling was done (black arrow). I and J : Follow-up anterior and lateral angiography showed stable occlusion of fistula. ICA : internal carotid artery, TCCF : traumatic carotid cavernous fistula.

Reference

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