Endovascular Management of Direct Carotid-Cavernous Fistula: Evolution of Cost Effective Sandwich Technique

Abstract

Objective There is a direct fistulous connection between the cavernous segment of the internal carotid artery and cavernous sinus in cases of direct carotid-cavernous fistula (CCF). Endovascular embolization is the mainstay of management in this condition. This study is about the evolution of endovascular treatment methods and the development of a cost-effective technique for embolization of direct CCF at a tertiary care center. Materials and Methods A retrospective analysis was performed of all the cases of direct type CCF embolized by endovascular techniques in our department from 2008 to 2018.Clinical follow-up of these patients was done at 1 week, 3 months, and 6 months. Results A total of 45 patients with 40 having a prior history of head trauma were included in this study. All cases were treated with a transarterial route except one which was treated with the transvenous approach. Detachable balloon s were used in 12 (26.67%) patients, only detachable coils in 14 cases (31.11%), both detachable balloons and coils in 9 cases (20%), and both detachable and push coils, that is, sandwich technique in 8 cases (17.78%). Parent arterial occlusion was performed in 10 patients (22.22%). There was complete resolution of chemosis and bruit in all the patients. Conclusion Endovascular treatment is the mainstay of management in direct CCF. Using more fibered thrombogenic coils in a sandwich manner decreases the cost of the treatment significantly.

Keywords: carotid cavernous fistula; detachable balloons; embolization; parent vessel occlusion; sandwich technique.

Fig. 1

( A ) Anteroposterior (AP) and ( B ) lateral projections of right internal carotid artery (ICA) digital subtraction angiography (DSA) showing direct carotid–cavernous fistula (CCF) with early opacification of cavernous sinus and superior ophthalmic vein. Also noticed complete steal phenomenon with nonopacification of distal ICA and its branches. ( C ) Left ICA DSA showing good cross flow. ( D ) Detachable balloon (arrow) deployed at the site of CCF defect. ( E ) AP and ( F ) lateral postprocedure projections of right ICA DSA showing complete occlusion of CCF defect and nonopacification of cavernous sinus in arterial phase.

Fig. 2

( A ) Anteroposterior (AP) and ( B ) lateral projections of left internal carotid artery (ICA) digital subtraction angiography (DSA) showing direct carotid–cavernous fistula (CCF) with opacification of bilateral cavernous sinuses, right superior ophthalmic vein, near complete steal phenomenon and contrast reflux into cortical veins on left side. Left superior ophthalmic vein was thrombosed and the patient presented with ocular symptoms predominantly on right side. ( C ) AP and ( D ) lateral projections showing a compliant balloon (arrow) in left cavernous ICA inflated at the site of CCF defect and initial deployment of coils in cavernous sinus and intercommunicating venous channel. ( E ) AP and ( F ) lateral projections of left ICA DSA showing cavernous sinus packed with multiple coils, occlusion of CCF and patent left ICA with good distal branches opacification..

Fig. 3

( A ) Clinical image at presentation showing proptosis and severe chemosis bilaterally. ( B ) Anteroposterior (AP) and ( C ) lateral projections of left left internal carotid artery (ICA) digital subtraction angiography (DSA) showing direct carotid–cavernous fistula (CCF) with early opacification of bilateral cavernous sinuses and superior ophthalmic veins. Complete steal is present with nonopacification of distal branches. ( D ) Right ICA DSA shows good cross flow through patent anterior communicating artery. ( E ) Parent artery occlusion with multiple coils. ( F ) Postprocedure day 3 clinical image showing complete resolution of proptosis and chemosis with features of residual sixth cranial nerve palsy on left side