High-flow carotid cavernous fistula and the use of a microvascular plug system: initial experience

Abstract

Purpose: We report our initial experience using a detachable microvascular plug system to occlude the internal carotid artery during endovascular treatment of high-flow carotid cavernous fistula.

Case and technique: An 87-year-old patient was admitted for acute-onset double vision with associated right-eye ptosis. Exam revealed a pupil-sparing, partial right third cranial nerve palsy. MRI showed a carotid cavernous fistula with high-flow drainage. Digital subtraction angiography showed a high-flow, right-sided, direct carotid cavernous fistula with flow from the proximal right internal carotid artery. The ophthalmic artery, posterior communicating artery and anterior communicating arteries supplied retrograde flow to the fistula through the internal carotid artery. Obliteration of the fistula was achieved through coil embolization in combination with proximal and distal microvascular plugs (Reverse Medical, Irvine, Calif., USA).

Conclusion: The microvascular plug is a new addition to current endovascular embolization devices for the treatment of high-flow, direct carotid cavernous fistulas. This technique offers easy navigability through tortuous arteries, precise localization and immediate occlusion, which may allow shorter procedure and fluoroscopy times and increased cost-effectiveness. Larger case series are needed to support our observation.

Keywords: Carotid cavernous fistula; High flow; Microvascular plug.

Fig. 1

The MVP device (Reverse Medical) is an ovoid-shaped, self-expanding device composed of nitinol partially covered with PTFE at the proximal portion.

Fig. 2

a, b Posteroanterior and lateral views of a left ICA injection showing a high-flow CCF filling the cavernous sinus. There is no opacification of the distal carotid artery beyond the fistula. The venous drainage occurs medially into the contralateral cavernous sinus through the intercavernous sinus, anteriorly into the superior and inferior ophthalmic veins and laterally along the sphenoparietal sinus into the superficial middle cerebral vein and refluxing into the cortical veins. c, d Oblique and lateral views of a left vertebral injection demonstrates partial filling of the right middle cerebral artery through a large PComA that also fills the fistula in retrograde fashion through the distal ICA.

Fig. 3

a Lateral plain film showing deployment of the MVP (arrow) into the horizontal cavernous segment of the right ICA. b Selective lateral injection of the vertebral artery reveals immediate absence of retrograde filling of the fistula from the distal ICA and a better filling of the right middle cerebral and anterior cerebral arteries after MVP deployment.

Fig. 4

a, b Plain films in posteroanterior and lateral views showing the MVP (arrow) in the ICA distal to the fistula and coil mass in the ICA proximal to the fistula. c, d DSA in lateral views of the right common carotid and left vertebral artery showing persistent complete anterograde and retrograde obliteration of the high-flow CCF.