Transarterial Embolization of Direct Carotid Cavernous Fistulas with the Double-balloon Technique

Abstract

Treatment of direct carotid cavernous fistulas (CCF) has progressed from surgical ligation to surgical trapping to endovascular techniques. Endovascular therapies are advantageous as they allow for occlusion of the fistula whilst preserving flow in the parent carotid artery. However, technical difficulties are not uncommon and occur when the fistulous orifice is too small or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Both circumstances may lead to technical failure or an unplanned sacrifice of the parent internal carotid artery (ICA). Here we describe a double-balloon technique used in the embolization of CCF in four patients that were successfully treated with complete immediate occlusion whilst preserving the parent ICA.

Figure 1

33-year-old-male (case 3 in table) with a left CCF following a car accident. A) Lateral projection of left ICA arteriogram shows direct type CCF with no filling of the intradural segment of the ICA. Note prominent ophthalmic, petrosal and pterygoid venous drainage. B) Lateral projection of left ICA arteriogram during embolization of fistula with the balloon protection technique. The detachable balloon, marked by a broad arrow, is for embolization. The wire-directed temporary occlusion balloon catheter, marked by a thinner arrow, is for temporary inflation inside the carotid artery as a protective balloon for the purpose of stabilizing the placement of the detachable embolization balloon at the time of detachment. C) Lateral projection of left ICA arteriogram immediately after embolization demonstrates resolution of the fistula whilst preserving a parent carotid artery. Note that the detachable balloon remains inside the cavernous sinus. D) Lateral projection of left ICA 3 months following embolization demonstrating no recurrent fistula or pseudoaneurysm formation. The detachable balloon is deflated.