Surgical Trapping of a Cavernous Carotid Aneurysm Causing Carotid Cavernous Fistula After Flow Diverter Placement: Technical Note and Literature Review

Abstract

Background: Flow diverter (FD) treatment is a promising therapeutic strategy for intracranial aneurysms such as cavernous carotid aneurysms (CCAs). Direct cavernous carotid fistula (CCF) caused by delayed rupture of FD-treated CCAs has been reported, and endovascular therapy has been used in the literature. Surgical treatment is warranted for patients who have failed or are ineligible for endovascular treatment. However, no studies have evaluated surgical treatment to date. Here, this paper presents the first case of direct CCF due to delayed rupture of an FD-treated CCA managed with surgical internal carotid artery (ICA) trapping with bypass revascularization, in which the intracranial ICA with FD placement was successfully occluded with aneurysm clips.

Methods: A 63-year-old man with a diagnosis of large symptomatic left CCA underwent FD treatment. The FD was deployed from the supraclinoid segment of the ICA distal to the ophthalmic artery to the petrous segment of the ICA. Since angiography 7 months after the FD placement showed progressive direct CCF, left superficial temporal artery-middle cerebral artery bypass followed by ICA trapping was performed.

Results: The intracranial ICA proximal to the ophthalmic artery where the FD was placed was successfully occluded using two aneurysm clips. The postoperative course was uneventful. Follow-up angiography 8 months after the surgery confirmed complete obliteration of the direct CCF and CCA.

Conclusions: The intracranial artery in which the FD was deployed was successfully occluded with two aneurysm clips. ICA trapping can be a feasible and useful therapeutic option to treat direct CCF caused by FD-treated CCAs.

Keywords: Aneurysm clip; Aneurysm trapping; Bypass; Cavernous sinus aneurysm; Delayed rupture; Flow diversion.