Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022;16(2):127-134.
doi: 10.5797/jnet.tn.2020-0115. Epub 2021 May 27.

Transarterial and Transvenous Coil Embolization of Direct Carotid-Cavernous Fistulas

Norihito Fukawa  1 , Nobuhiro Nakagawa  2 , Kiyoshi Tsuji  1 , Hiromasa Yoshioka  1 , Kentaro Furukawa  1 , Kazuhiro Nagatsuka  3 , Hisashi Kubota  3 , Naoki Nakano  1 , Jun C Takahashi  1
Affiliations

Transarterial and Transvenous Coil Embolization of Direct Carotid-Cavernous Fistulas

Norihito Fukawa et al. J Neuroendovasc Ther. 2022.

Abstract

Objective: Transvenous embolization (TVE) is typically used in combination with the residual shunt of transarterial embolization (TAE) for the treatment of direct carotid-cavernous fistulas (direct CCFs). This report is about our additional embolization method using combination therapy.

Case presentation: Five consecutive cases of direct CCF were presented; two were caused by aneurysms and three by head injuries. The treatment for each was started with TAE, with the addition of TVE if a shunt remained. At the time of TVE, a microcatheter positioned in the internal carotid artery passing from the cavernous sinus through the aneurysm neck or fistula was pulled back (pull-back method). It was then placed in the coil mass with TAE, and additional coils were filled. In two cases, the shunt disappeared by using only TAE, whereas it disappeared after being additionally embolized by the pull-back method in the remaining cases. All patients recovered with no postoperative complications.

Conclusion: The TAE and TVE combination therapy with the pull-back method could efficiently embolize the residual shunt after TAE.

Keywords: cavernous sinus packing; detachable coils; fistula involved compartment; transfistula catheterization.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1. Pull-back method. (A) Direct CCFs (large type) related to ruptured aneurysms. Red arrows show blood flow. (B) Preparations for TAE: a microcatheter was inserted into an aneurysm. The balloon-assisted technique was adopted. (C) Preparations for TVE: a microcatheter was guided into the aneurysm in CS through the IPS, passed through the aneurysmal neck, and placed in the ICA. (D) Pull-back method: a TVE microcatheter was pulled back (red dotted line) and guided to a coil mass placed during TAE. (E) Additional embolization (green line) was performed using the microcatheter placed in the coil mass. CCF: carotidcavernous fistula; CS: cavernous sinus; ICA: internal carotid artery; IPS: inferior petrosal sinus; SMCV: superficial middle cerebral vein; SOV: superior ophthalmic vein; TAE: transarterial embolization; TVE: transvenous embolization
Fig. 2
Fig. 2. (A) An aneurysm was observed in the C5 portion of the right ICA. The SOV and IPS were shunt drainage pathways. (B) 3D angiography. The aneurysm measuring 6.4 mm × 4.1 mm and cavernous sinus were visualized. (C) Working angle. Relationship between the neck and aneurysm in the C5 portion of the right ICA. (D) Right VAG. Under right cervical compression, the neck (arrowhead) was visualized in the C5 portion of the right ICA through the Pcom. (E) MPR, axial view. ICA (arrow) and aneurysmal neck (arrowhead). (F) MPR, working angle. Relationship between the ICA and aneurysmal neck (arrowhead). ICA: internal carotid artery; IPS: inferior petrosal sinus; MPR: multiplanar reconstruction; Pcom: posterior communicating artery; SOV: superior ophthalmic vein; VAG: vertebral arteriography
Fig. 3
Fig. 3. (A) Working angle. The aneurysmal neck (arrowhead) was separated from the ICA. A TAE microcatheter was inserted into the aneurysm (arrow). (B) A TVE microcatheter was passed through the neck from the cavernous sinus and placed the C2 portion of the ICA (arrowhead). Another microcatheter was placed in the SOV (arrow). (C) LAT view. A Target XL 360 Soft 7 mm × 20 cm was inserted into the aneurysm and adjoining compartment to prepare a frame. A coil loop (arrowhead) placed in the adjoining compartment, being stabilized. (D) Five coils were placed and the shunt volume decreased. Under balloon assistance, the additional insertion of a coil measuring 3 mm in diameter through the TAE microcatheter became difficult. (E) A TVE microcatheter placed in the ICA (arrowhead) was guided to a coil mass using the pull-back method (arrow) coaxially with a microguidewire and placed in an area adjacent to the neck. (F) Coils were additionally placed in the coil mass through the TVE microcatheter, leading to the disappearance of the shunt. ICA: internal carotid artery; LAT: lateral; SOV: superior ophthalmic vein; TAE: transarterial embolization; TVE: transvenous embolization
Fig. 4
Fig. 4. Direct CCFs related to ruptured aneurysms. (A) Small type; a small connection with an adjoining compartment. As the part of connection with an adjoining compartment is small, it is possible to embolize only the aneurysm. (B) Large type; a large connection with an adjoining compartment. As the part of connection between the aneurysm and adjoining compartment is large, the frame size increases and the size of a site to be embolized may be increased. Red arrows show blood flow. CCF: carotidcavernous fistula; ICA: internal carotid artery; IPS: inferior petrosal sinus; SMCV: superficial middle cerebral vein; SOV: superior ophthalmic vein
Fig. 5
Fig. 5. Direct CCFs related to fistula formation. (A) Simple type without an adjoining compartment. The fistula-involved compartment is a minimal compartment to be embolized, facilitating compact embolization. (B) Complex type with an adjoining compartment. When the part of the connection between fistula-involved and adjoining compartments is large, the size of a site to be embolized may be increased. ICA: internal carotid artery; IPS: inferior petrosal sinus; SMCV: superficial middle cerebral vein; SOV: superior ophthalmic vein
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

References

    1. Henderson AD, Miller NR. Carotid-cavernous fistula: current concepts in aetiology, investigation, and management. Eye (Lond) 2018; 32: 164–172. - PMC - PubMed
    1. Andrade G, Ponte De Souza ML, Marques R, et al. . Endovascular treatment of traumatic carotid cavernous fistula with balloon-assisted sinus coiling. A technical description and initial results. Interv Neuroradiol 2013; 19: 445–454. - PMC - PubMed
    1. Chi CT, Nguyen D, Duc VT, et al. . Direct traumatic carotid cavernous fistula: angiographic classification and treatment strategies. Study of 172 cases. Interv Neuroradiol 2014; 20: 461–475. - PMC - PubMed
    1. Ito Y, Satow T, Matsubara H, et al. . Selective shunt occlusion of direct carotid-cavernous fistula with vascular Ehlers-Danlos syndrome by multidevice technique: a case report and technical note. World Neurosurg 2019; 122: 123–128. - PubMed
    1. Kojima A, Onozuka S, Ishikawa M, et al. . Usefulness of the ED coil inifini for the treatment of direct carotid-cavernous fistula: technical note. JNET J Neuroendovasc Ther 2012; 6: 61–67.