Carotid cavernous fistulas treated by endovascular covered stent grafts with follow-up results

Historically, carotid cavernous fistulas (CCFs) are usually treated with detachable balloons and coils. While coronary covered stent grafts have been sporadically used in the intracranial vasculature, only a few such cases have been reported in the literature. We present our experience of seven patients with eight CCFs, treated by the placement of covered stents, and provide their clinical and angiographic follow-up results. From 28 cases of CCF treated at our department between November 2000 and January 2007, a total of eight post-traumatic CCF were treated between May 2005 and January 2007 by positioning a Jostent coronary stent graft (Abbott Vascular, Redwood City, CA) in the intracranial ICA. These patients had periodic follow-up examinations (at 12-30 months) with 5 of them receiving a follow-up angiographic examination (at 6-9 months). Immediate post-procedural angiograms demonstrated total exclusion in five CCFs, residual filling in three CCFs, and preserved ICA patency in all CCFs. Symptoms related to the CCF regressed within 1-15 days after the covered stent placement. There was no mortality and no immediate post-procedural morbidity related to the CCF covered stent treatment; however, one patient died of acute myocardial infarction in 10 days following treatment. Six patients showed complete clinical recovery during their clinical follow-up. The angiographic follow-up (mean, 8 months) in five patients with six CCFs revealed regressed residual filling, stable occlusion of all CCFs, and an ICA patency (one case of asymptomatic ICA occlusion) rate of 83.3%. Covered stents are a promising therapeutic alternative for patients with CCF in whom fistulas cannot be successfully occluded with detachable balloons or coils. Our results and the reported results showed that a covered stent could occlude the fistula and preserve the ICA without hemodynamic changes or negative clinical effects. Covered stent grafts could soon become a first-line therapy as experience with this device increases, materials continue to improve, and more data are accumulated.