Transarterial balloon-assisted n-butyl-2-cyanoacrylate embolization of direct carotid cavernous fistulas

Abstract

Background and purpose: Transarterial detachable balloon embolization of direct carotid cavernous fistulas (DCCFs) has become an optimal treatment. In a few cases, the parent artery has to be sacrificed to achieve morphologic cure. We present our experience with transarterial balloon-assisted n-butyl-2-cyanoacrylate (n-BCA) embolization of DCCFs in which there was failure to achieve angiographic cure and preservation of parent arteries.

Methods: Of 141 patients with traumatic DCCFs who had been treated by transarterial embolization with occlusion of the fistula and parent artery preservation, 18 received transarterial balloon-assisted n-BCA embolization-6 for residual fistula after the balloons detached, 7 for recurrent fistula because of premature balloon deflation or migration, and 5 for repeated puncture of the detachable balloon by the bony fragment at the cavernous sinus. A total of 27 procedures were performed with an average 1.5 attempts per patient, and the volume of the n-BCA mixture varied from 0.5 to 2.3 mL with a mean of 0.83 mL.

Results: All DCCFs were successfully occluded by the n-BCA mixture with preservation of parent arteries. One patient with a giant cavernous sinus varix had a fatal subarachnoid hemorrhage. One had a recurrence and was treated by internal carotid artery (ICA) occlusion. Five had asymptomatic pseudoaneurysms at the parent artery. There was no adhesion of the n-BCA mixture to the protective balloon or the microcatheter or n-BCA reflux into the parent arteries.

Conclusion: Transarterial balloon-assisted n-BCA embolization is a feasible, efficient, and safe treatment for DCCFs when angiographic cure and ICA preservation are not achieved by transarterial detachable balloon embolization.

Fig 1.

Images of a 49-year man with a traumatic DCCF and a traumatic aneurysm at the left supraclinoid ICA. A, Left lateral carotid angiogram reveals a residual fistula after a detachable balloon embolization. B and C, Two GDCs were placed into the cavernous sinus. Further coil embolization to achieve angiographic cure failed because of recoil of the microcatheter, and the traumatic aneurysm was occluded by GDC (arrowhead). Under a protective balloon (arrows) at the cavernous portion of the ICA, a total of 0.5 mL of n-BCA mixture was infused into the cavernous sinus. D, Postembolization angiogram reveals total obliteration of the residual fistula with preservation of the ICA flow.

Fig 2.

Images of a 40-year-old man with traumatic DCCF. A, Right lateral carotid angiogram shows a residual fistula after 2 detached balloons and 1 coil embolization. B, A total of 1.1 mL n-BCA mixture was slowly deposited to the cavernous sinus in 2 attempts. C, Postembolization angiogram shows total occlusion of the fistula with ICA preservation.

Fig 3.

Images of a 38-year-old woman with a DCCF; the DCCF was successfully occluded by a detached balloon with patency of the ICA. A, Premature balloon deflation causes recurrent DCCF and drains to the superior ophthalmic vein. Navigation of the additional balloon into the cavernous sinus failed because of blockage by a previously detached balloon (arrow). B and C, One GDC and 0.7 mL of n-BCA mixture were injected into the cavernous sinus under a protective balloon at the cavernous portion of the ICA (arrows), resulting in an angiographic cure of the recurrent DCCF with ICA preservation. Note a small asymptomatic false sac (arrowhead) at the cavernous sinus owing to insufficient NBCA filling.

Fig 4.

Images of a 50-year-old man in whom the DCCF failed to occlude because of repeated puncture of the balloons. A, Left lateral angiogram shows a DCCF. B and C, The fistula was successfully obliterated with ICA preservation by a microcoil and 1 mL of n-BCA mixture.