Transvenous detachable coil embolization of direct & high-flow carotid-cavernous fistula. Alternative of transarterial detachable balloon embolization

Abstract

We encountered 8 cases of high-flow and direct carotid cavernous fistula (CCF) since 1994. Four patients were treated with transarterial fistula occlusions using detachable balloons before 1997. Complete obliteration of CCFs with preservation of internal carotid artery (ICA) were achieved in all 4 cases using each one balloon. Three cases were approached to the fistulas via the percutaneous transfemoral approach, but one aged patient needed a direct carotid puncture because of her tortuous vessels. Meanwhile, transvenous embolizations with detachable coils (DCs); Guglielmi detachable coil (GDC), interlocking detachable coil (IDC) and fibered platinum coil were attempted in four cases after 1997; in 2 cases after failure of transarterial approach and in 2 as initial form of treatment. All 4 cases were successfully approached to the cavernous sinuses (CS) through the inferior petorosal sinus (IPS). At first we intended to block dangerous outflow points for the superior ophthalmic vein (SOV), cortical venous reflux (CVR) and contra-lateral CS. And then obliteration of the fistulas were performed with tight packing of GDCs covering the outside of the ICA. At this time, the arteriovenous shunts were disappeared abruptly, so we finished all procedure without occlusion of IPS.We compared the two methods and concluded that the transvenous embolizaton with DCs is an useful alternative of transarterial detachable balloon therapy of high flow CCF, especially when transarterial approach is difficult or proper balloons are not available.

Figure 1

Case 1. Right internal angiogram (A) shows high-flow CCF drain to SOV. The fistula site is not identified because of enlarged cavernous sinus. Angiogram with proximal flow control shows the fistula site and shape (B). Angiogram under test inflation of a detachable balloon. Note that the bent of microcatheter. The dots line indicates the shape of catheter and balloon (C). Angiogram of post embolization show obliteration of CCF. Note that the tail of detached balloon slighty protrudes within ICA (D).

Figure 2

Case 5. Right common carotid angiograms show ipsi-lateral extensive cortical reflux (A) and severe bilateral SOV enlargement (B). A selective venography after the right SOV occlusion with GDCs shows only cortical drainage (C). An angiogram after additional embolizations at the point does not show any cortical venous reflux yet (D). Right common carotid angiograms of post embolization show completely obliteration of CCF (E). Note that, a part of GDC migrated to the left cavernous sinus through the intercavenous sinus (F).

Figure 2

Case 5. Right common carotid angiograms show ipsi-lateral extensive cortical reflux (A) and severe bilateral SOV enlargement (B). A selective venography after the right SOV occlusion with GDCs shows only cortical drainage (C). An angiogram after additional embolizations at the point does not show any cortical venous reflux yet (D). Right common carotid angiograms of post embolization show completely obliteration of CCF (E). Note that, a part of GDC migrated to the left cavernous sinus through the intercavenous sinus (F).

Figure 3

Illustrated image of transarterial detachable balloon occlusion of direct CCF. The balloon is lodged at the fistula site and fistula occlusion is completed at the moment of inflation. Almost complications are depend upon balloon techniques and intraarterial maneuvers.

Figure 4

Illustrated image of transvenous detachable coil embolization of direct CCF. This procedures are performed within CS only. The risk of thromboemobolic complications is very low. The dangerous drainages of SOV and CVR should be blocked at the initial stage for safety. The fistula site is covered from the outside like a gate closed by large and long coils. This fashion of occlusion is feasible to preserve the patency of ICA.