Endovascular treatment of traumatic carotid cavernous fistula with balloon-assisted sinus coiling. A technical description and initial results

Abstract

This study aimed to propose an alternative treatment for carotid cavernous fistula (CCF) using the balloon-assisted sinus coiling (BASC) technique and to describe this procedure in detail. Under general anesthesia, we performed the BASC procedure to treat five patients with traumatic CCF. Percutaneous access was obtained via the right femoral artery, and a 7F sheath was inserted, or alternatively, a bifemoral 6F approach was accomplished. A microcatheter was inserted into the cavernous sinus over a 0.014-inch microwire through the fistulous point; the microcatheter was placed distal from the fistula point, and a "U-turn" maneuver was performed. Through the same carotid access, a compliant balloon was advanced to cross the point of the fistula and cover the whole carotid tear. Large coils were inserted using the microcatheter in the cavernous sinus. Coils filled the adjacent cavernous sinus, respecting the balloon. Immediate complete angiographic resolution was achieved, and an early angiographic control (mean = 2.6 months) indicated complete stability without recanalization. The clinical follow-up has been uneventful without any recurrence (mean = 15.2 months). An endovascular approach is optimal for direct CCF. Because the detachable balloon has been withdrawn from the market, covered stenting requires antiplatelet therapy and its patency is unconfirmed, but cavernous sinus coiling remains an excellent treatment option. Currently, there is no detailed description of the BASC procedure. We provide detailed angiograms with suitable descriptions of the exact fistula point, and venous drainage pathways. Familiarity with these devices makes this technique effective, easy and safe.

Keywords: carotid artery; cavernous sinus fistula; embolization; endovascular treatment; trauma.

Figure 1

A) The exact location of the fistula and a compliant balloon, which crosses the fistula and covers the whole carotid tear, and a microcatheter located in the cavernous sinus after a “U-turn” maneuver. B) The location where large coils should be placed, respecting the balloon.

Figure 2

A) Lateral view of a left ICA angiogram showing a high-flow CCF draining into the left superior and inferior ophthalmic vein. B) Rotational acquisition demonstrates the exact location of the fistula (asterisk). C) Lateral view of the left ICA angiogram reveals two microcatheters with the first being inserted into the cavernous sinus (filled arrow) and the balloon along the internal carotid (open arrow). D,E) Immediate angiograms confirmed a complete obliteration of the fistula with 12 coils. F) Three months after the angiogram, a complete resolution of the CCF was observed. ICA, internal carotid artery; CCF, carotid cavernous fistula.

Figure 3

A) Lateral view of a left ICA angiogram showing a high-flow CCF draining into the left superior and inferior ophthalmic vein and inferior petrosal sinus. B) Lateral view of a left ICA angiogram showing intense cortical venous reflux. C) Angiographic view of compliant balloon (open arrow) and cast of coils. D) Immediate angiogram in lateral view demonstrated a complete resolution of the CCF. E,F) One month later, control angiograms revealed a reduction of the cortical drainage and a complete resolution of the CCF. ICA, internal carotid artery; CCF, carotid cavernous fistula.

Figure 4

A) Lateral view of a left ICA angiogram showing a high-flow CCF draining into the left superior ophthalmic vein and inferior petrosal sinus. B) Anterior-posterior view in the venous phase, showing CCF draining into the contralateral CS. C) Angiographic view of the compliant balloon and a cast of coils. D) Three months later, a control angiogram revealed a complete resolution of the CCF. ICA, internal carotid artery; CCF, carotid cavernous fistula; CS, cavernous sinus.

Figure 5

A) Antero-posterior view of a right ICA angiogram showing a high-flow CCF, with intense cortical reflux at lateral angiography (B), and status post BASC procedure with a dense cast of coils (C). D) Two months later, a control angiogram revealed a complete resolution of the CCF with no cortical reflux. ICA, internal carotid artery; CCF, carotid cavernous fistula.

Figure 6

A) Clinical picture of a left eye chemosis associated with paralysis of the ipsilateral III, IV and VI cranial nerves. B) Lateral view of a left ICA angiogram showing a high-flow CCF draining into the left superior and inferior ophthalmic vein and inferior petrosal sinus. C) Lateral view of a left ICA angiogram showing two microcatheters with the first being inserted into the cavernous sinus (filled arrow) and a compliant balloon along the internal carotid (open arrow). D) Angiography lateral view of the inflated balloon (asterisk) and a partial cast of coils. E) Three months later, a control angiogram revealed a complete resolution of the CCF. F) The patient's clinical follow-up was uneventful. ICA, internal carotid artery; CCF, carotid cavernous fistula.