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Cure of a direct carotid cavernous fistula by endovascular stent deployment
W Weber1, H Henkes, E Berg-Dammer
1Klinik für Radiologie und Neuroradiologie, Alfried Krupp Krankenhaus, Essen, Deutschland.
Insights
A carotid cavernous fistula developed post-surgery for carotid artery stenosis. Endovascular stent repair successfully closed the fistula, preserving blood flow in the internal carotid artery (ICA).
Area of Science:
- Vascular Surgery
- Interventional Neuroradiology
- Ophthalmology
Background:
- Surgical thrombendarterectomy for atherosclerotic internal carotid artery (ICA) stenosis can rarely lead to complications.
- Postoperative development of cranial nerve palsies and ophthalmopathy suggests a potential vascular complication.
Observation:
- A 53-year-old woman developed a direct carotid cavernous fistula (CCF) following left ICA thrombendarterectomy.
- Clinical signs included sixth cranial nerve palsy, proptosis, chemosis, and ciliary injection in both eyes.
- Digital subtraction angiography confirmed the left ICA-cavernous sinus fistula with superior ophthalmic vein involvement.
Findings:
- Endovascular treatment was employed to occlude the CCF.
- Initial attempts with detachable balloons failed to obliterate the fistula while maintaining ICA patency.
- Successful fistula occlusion was achieved using stent deployment over the rupture site, preserving the ICA.
Implications:
- This case demonstrates the successful endovascular management of a direct CCF complicating carotid endarterectomy.
- The use of flexible coronary stents facilitates access to tortuous vessels like the distal ICA.
- Stent deployment combined with balloon embolization offers a viable strategy for treating complex CCFs, ensuring ICA patency.
Abstract:
A 53-year-old woman underwent surgical thrombendarterectomy for treatment of artherosclerotic stenoses of her left internal carotid artery (ICA). A Fogarty catheter was used during this operation. The postoperative course was complicated by the development of a sixth cranial nerve palsy, protrusio, chemosis and ciliar injection of both eyes. Digital subtraction angiography showed a direct fistula between the cavernous segment of the left ICA and the cavernous sinus, with early and retrograde opacification of both superior ophthalmic veins. Endovascular occlusion of the fistula was achieved with preservation of the ICA by stent deployment over the rupture site of the ICA, as two detachable balloons could not obliterate the fistula while preserving the ICA patent. Follow-up angiography 7 months after the endovascular treatment confirmed persisting occlusion of the fistula with a patent ICA. Highly flexible porous coronary stents can easily be introduced into tortuous vessels, including the distal ICA. The haemodynamic effects achieved by stent deployment together with two balloons detached in the cavernous sinus may be sufficient to interrupt a direct carotid cavernous fistula.