Transvenous Embolization of Carotid Cavernous Fistula through Inferior Petrosal Sinus with Detachable Coils and Ethylene Vinyl Alcohol Copolymer
Summary
The purpose of the article is to present our experience in endovascular treatment via the inferior petrosal sinus of the carotid cavernous fistula with detachable coils and ethylene-vinyl alcohol copolymer.
Abstract
Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal branches of the external carotid artery (indirect fistula) and the cavernous sinus (CS). Trauma is the most common cause of CCF. The clinical presentation of CCF is closely related to the venous drainage pattern. Orbital and neuro-ophthalmological symptoms are the most common clinical presentation of CCF with drainage through the superior ophthalmic vein (SOV). Endovascular embolization by arterial or venous approaches is the most common management of CCF. Transvenous embolization using detachable coils and ethylene-vinyl alcohol copolymer (EVOH) is an alternative method for the treatment of CCF. Endovascular embolization offers different options to treat CCF by minimally invasive approach decreasing morbidity and residual fistulas. The purpose of this article is to report our treatment experiences via the inferior petrosal sinus (IPS), and immediate-term outcomes of endovascular embolization of CCF by using detachable coils and EVOH.
Introduction
Carotid cavernous fistula (CCF) is defined as abnormal arteriovenous communications between the internal carotid artery or meningeal branches of the external carotid artery and the cavernous sinus1. CCF can be classified based on the etiology (traumatic or spontaneous), flow rate (high or low flow), or the angiographic composition (direct or indirect)1,2. The clinical presentation of CCF is closely related to the venous drainage pattern: orbital and neuro-ophthalmological symptoms associated with drainage via the SOV, whereas neurological symptoms or intracranial hemorrhage related to leptomeningeal drainage3,4.
The main treatment for CCF includes observation, intermittent manual compression of the common carotid artery (CCA), stereotactic radiosurgery and endovascular embolization2,3. Ethylene vinyl alcohol copolymer (EVOH) is a non-adhesive liquid embolic material that was firstly evaluated at UCLA Medical Center between January 1998 and May 19995. The treatment has changed with the development of the transvenous approach in association with detachable coils and EVOH. CCF is treated by endovascular techniques evolved from unimodality (transarterial detachable balloon occlusion) to multimodality (transarterial/intravenous coils, detachable balloon, liquid embolic agents, endovascular stent, etc)5,6,7. Recently, transvenous endovascular embolization has become a standard treatment for CCF because of its feasibility and safety3,6,7. There are several venous approaches based on the type of venous drainage. If the CCF has a mainly posterior venous drainage, through the inferior petrosal sinus (IPS), this route is the simplest and shortest in most patients. Even if it cannot be shown on angiographical images or it is thrombosed, catheters can still be guided into the CS through it.
We report successful endovascular treatment of 7 CCF patients using detachable coils and EVOH via the inferior petrosal sinus. The technical details are described in this protocol. The final decision to treat with a transarterial or transvenous approach was made after the analysis of the clinical images, and angiographic findings in each case. Based on our prior experience of treating CCF procedures by transarterial or transvenous approaches, we have found that endovascular embolization via the inferior petrosal sinus is a very good option with good outcomes, also safer and more effective than that via arterial access3,6.
Protocol
Representative Results
Discussion
Recently, endovascular treatment has become the most common therapy for CCFs. Successful treatment of CCFs is to occlude the abnormal shunts between the ICA or meningeal branches of the external carotid artery and the CS while keeping the ICA unobstructed. The treatment can be achieved with transarterial or transvenous approach to obliterate the affected side CS with coils or other embolic materials. Some patients with direct CCFs can be cured with the deployment of a covered stent across the fistula through ICA. The dis…
Offenlegungen
The authors have nothing to disclose.
Acknowledgements
We acknowledge fellowship from the Interventional Radiology Center of 1st Affiliated Hospital of Zhejiang University.
Materials
| EV3 coil | Medtronic, Irvine, California, USA | material for endovascular treatment | |
| MicroPlex coil | MicroVention, California, USA | material for endovascular treatment | |
| EVOH | Medtronic, Irvine, California, USA | material for endovascular treatment | |
| Echelon/microcatheter | Medtronic, Irvine, California, USA | interventional material | |
| Envoy/guiding catheter | Johnson & Johnson Company,USA | interventional material | |
| vascular sheath | Terumo Corporation, Tokyo, Japan | interventional material |
Referenzen
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