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[Iatrogenic carotid-cavernous fistulas, complications of carotid thrombectomy]
Insights
Four patients developed carotid cavernous fistulas after carotid artery embolectomy using a Fogarty catheter. Age and carotid siphon atherosclerosis are key risk factors for this iatrogenic complication.
Area of Science:
- Vascular Surgery
- Interventional Neuroradiology
- Cerebrovascular Disease
Background:
- Carotid bifurcation stenosis and postoperative thrombosis are treated with embolectomy using Fogarty catheters.
- Endoluminal treatments for vascular lesions are increasingly common.
- Iatrogenic complications require careful consideration during endovascular procedures.
Observation:
- Four cases of carotid cavernous fistula (CCF) at the C5 segment of the internal carotid artery (ICA) following Fogarty catheter embolectomy are reported.
- Patients had carotid bifurcation stenosis, with thrombectomy performed during initial surgery or re-operation.
- Fistulas manifested between one day and two months post-surgery.
Findings:
- Two patients experienced spontaneous recovery (occlusion/re-stenosis).
- One patient died due to contralateral carotid occlusion; another was lost to follow-up.
- No correlation was found between repeated Fogarty catheter passes and fistula onset time, but fistula location was consistent.
- Overtension of the ICA wall by the catheter balloon is a potential cause, rather than collateral tearing.
Implications:
- Age and atheromatous lesions of the carotid siphon are identified as primary risk factors for CCF post-embolectomy.
- Vigilance for iatrogenic carotid cavernous fistulas is crucial during endovascular interventions.
- Understanding risk factors and mechanisms can help prevent similar complications in endovascular procedures.
Abstract:
The authors report four cases of carotid cavernous fistula at the C5 segment of the internal carotid artery following embolectomy by a 3F Fogarty Catheter. All patients were operated on a carotid bifurcation stenosis (pre-occlusive) and a thrombectomy with a 3F Fogarty Catheter was carried out in the same time in 3 patients and during re-operation in 1 patient who had post operative thrombosis. The carotid-cavernous fistula occurred the day after surgery in 2 cases, 1 week after in 1 case, and 2 months later in 1 case. Spontaneous recovery occurred in two patients (1 occlusion--1 re-stenosis), 1 patient died from controlateral carotid occlusion, and 1 patient was lost for investigation. There were no relationship between the number of "repeated passages" of the Fogarty Catheter and the interval time where the fistula occurred. However the location of fistula was constant. Overtension on the internal wall of the artery by the balloon could be advocated rather than a collateral torn of the intra cavernous internal carotid. Endoluminal treatment of various vascular lesion is increasingly used and iatrogenic problems as reported here should be kept in mind. Age and atheromatous lesion of carotid siphon appear to be the main risk factors.