Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients

Abstract

Background and purpose: Carotid cavernous fistulas (CCF) can be effectively treated by using different therapeutic alternatives such as detachable balloons and detachable coils, alone or in combination with N-butyl-2-cyanoacrylate (n-BCA) or Onyx. Stents have also been used in an attempt to improve preservation of the parent artery while still occluding the fistula. We present our experience using balloon-expandable covered stents to treat CCF, focusing on arterial wall reconstruction. To our knowledge, this is the first series with midterm follow-up between 3 months and 3.5 years.

Materials and methods: From the 46 CCF treated at our institution between November 1998 and September 2006, a total of 7 posttraumatic direct CCF were treated using polytetrafluoroethylene (PTFE)-covered stents between April 2003 and September 2006. Five were treated with covered stents alone. One patient with transection of the internal carotid artery (ICA) first underwent bare stent placement to provide support for the covered stent. One patient had to be treated with coils and n-BCA.

Results: Control angiograms obtained in the 7 patients demonstrated occlusion of the fistula and preservation of the ICA in all cases. There was no mortality and no immediate postprocedural morbidity. There was 1 case of morbidity identified at 1-month follow-up with asymptomatic occlusion of the ICA; the other 6 patients had angiographic follow-up between 3 and 42 months (mean, 18.4 months), with persistent occlusion of the fistulas, patent stent grafts, and no significant intimal hyperplasia.

Conclusions: PTFE-covered stents are evolving as a promising intracranial therapeutic alternative to treat CCF and preserve the parent artery by reconstructing the arterial wall. They should be considered in patients in whom fistulas cannot be successfully occluded with detachable balloons or detachable coils. More investigation is required to further develop their specifications and indications.

Fig 1.

A, Patient 2. Selective left ICA angiogram demonstrates a CCF after a gunshot wound, with filling of the superior ophthalmic vein (black arrow) and inferior petrosal sinus (white arrow). B, Immediate control post-covered stent deployment (black arrow) shows complete occlusion of the fistula. A small pseudoaneurysm is noticed in the petrous carotid artery (black arrowhead), which was managed conservatively. C, Follow-up after 15 months shows a normal artery without recanalization of the fistula. There has been spontaneous resolution of the small pseudoaneurysm, and there is no intimal hyperplasia.

Fig 2.

A and B, Patient 4. Angiogram with arterial (A) and venous (B) phase images showing a CCF with retrograde cortical venous drainage (black arrows and white arrowhead). Notice the separation of the cortical veins due to the intracerebral hematoma identified in a previous MR image (not shown). In this case, a covered stent was used because the fistula was too small to accept a balloon. C, Control poststent graft deployment (white arrows). There is complete occlusion of the fistula. D, Fifteen-month control angiogram demonstrates persistent occlusion of the fistula with minimal intrastent intimal hyperplasia (black arrow), which remained stable in the 42-month angiographic follow-up (not shown).

Fig 3.

A, Patient 5. Selective right ICA angiogram demonstrates a high-flow CCF with arterial phase enhancement of a markedly enlarged superior ophthalmic vein (black arrow), facial veins (white arrowheads), and both inferior petrosal sinuses (curved arrows). This is a case of near-complete cavernous ICA transection with nonvisualization of the right anterior and middle cerebral arteries due to complete deviation of the flow into the fistula. B, There is an exchange wire stabilized in one of the distal middle cerebral artery branches. A bare stent has just been deployed in the cavernous carotid artery to reconstruct the vessel wall and provide stability to the covered stent, which is being positioned inside the bare stent at the exact location of the fistula. C, Control postdeployment shows occlusion of the fistula with re-establishment of the intracranial flow through the right ICA. There is straightening (arrow) of the cavernous ICA with no hemodynamic consequence in the control angiogram. D, Three-month follow-up with CT angiography. Here the sagittal reformat shows the straightening of the cavernous carotid artery with the stent in place and preserved patency. E and F, Angiographic follow-up at 8 and 15 months demonstrates a normal intracranial ICA without recurrence of the fistula or significant intrastent intimal hyperplasia (black arrows).