Angiographic follow-up of traumatic carotid cavernous fistulas treated with endovascular stent graft placement

Abstract

Background and purpose: Endovascular treatment (EVT) of carotid cavernous fistulas (CCFs) is based on various techniques, mainly those using detachable balloons. Coronary covered stent grafts have been sporadically used in the intracranial arteries and only 2 traumatic CCFs have been reported in the literature; moreover, there is poor information about the long-term follow-up. We present 8 cases of CCFs treated by the placement of a covered stent, 5 of which have a 1-year clinical and angiographic follow-up.

Methods: Eight patients with posttraumatic CCF were treated by positioning a covered stent in the intracranial internal carotid artery (ICA) to occlude the fistula. They received periodic clinical and angiographic follow-up to evaluate the patency and the stability of clinical results.

Results: In all cases, the symptoms related to the CCF regressed after treatment and did not recur in the follow-up. Two patients presented residual filling of the CCF at the end of the procedure. The angiographic follow-up revealed in 6 patients of 7 a good patency of the ICA; in 1 patient, there was an ICA asymptomatic occlusion. One patient required transvenous coil occlusion of the cavernous sinus.

Conclusion: When standard treatments fail, covered stent grafts can be used as a valid alternative in the treatment of CCFs, but more data are needed, especially in the long-term follow-up.

Fig 1.

Case 3. A and B, lateral right ICA angiograms show the CCF before (A) and after (B) treatment; arrows point to stent extremities. C, lateral view showing the stent and 4 detachable balloons previously used; 2 balloons partially inflated were used in an attempt to occlude the right CCF, whereas the 2 deflated balloons occluded the left CCF 2 months earlier.

Fig 2.

Case 8. A, Lateral angiogram of the ICA showing total steal of the flow toward the cavernous sinus; vertebral and contralateral ICA angiographies (not reported) showed steal also from posterior and contralateral circulation. B, Lateral ICA angiogram at the end of the stent-graft placement procedure showing nearly complete occlusion of the CCF. C and D, ICA angiogram in lateral projection of day 2 after treatment showing partial reopening of the fistula (C) and the result after angioplasty with a coronary balloon. E, Lateral ICA angiogram 3 months later showing persistence of the fistula with regularization of intracranial hemispheric circulation (note different diameter of distal ICA and posterior communicating artery between D and E).

Fig 3.

Case 5. Lateral angiograms show the postprocedural occlusion of the CCF (A) and the intimal hyperplasia causing a 30% reduction of the ICA lumen at the 6-month follow-up (B), with a possible improvement at the 1-year follow-up (C). Arrows point to the stent extremities. The marker of the previously released balloon is visible anterior to the ascending segment of the carotid siphon.