Endovascular treatment of spontaneous indirect high flow carotid cavernous fistula with a covered stent.
" Pakistan Journal of Neurological Sciences (PJNS): Vol. 9 : Iss. 4
stent.
Qasim Bashir 2
Bahria Town Hospital 2
Lahore 2
Pakistan. 2
2
Bahria Town Hospital 2
Lahore 2
Pakistan. 2
0 Department of Anesthesia, Bahria Town Hospital , Lahore , Pakistan
1 Department of Interventional Neurology, Bahria Town Hospital , Lahore , Pakistan
2 Dr.Qasim Bashir
-
ENDOVASCULAR TREATMENT OF SPONTANEOUS INDIRECT
HIGH FLOW CAROTID CAVERNOUS FISTULA WITH A
COVERED STENT.
Correspondence to: Dr.Qasim Bashir, Department of Interventional Neurology, Bahria Town Hospital, Lahore, Pakistan. Email:
Date of submission: July 5, 2014, Date of revision: August 25, 2014, Date of acceptance: September 12, 2014
Objective: The treatment of symptomatic carotid-cavernous fistulas [CCF] has been historically treated in the
developed world through the endovascular route. We report our first case of using a covered stent in a patient with
spontaneous CCF. Method: Single patient with spontaneous indirect high flow CCF treated with a covered stent. We present
retrospective analysis of technical success, initial and 6-month follow-up angiography and clinical outcome. Result:
The stent was successfully navigated and deployed covering the CCF orifice. Immediate post stent deployment
angiography showed marked reduction in flow and complete occlusion at 6-months. Clinically, patient showed near-complete
recovery at 6 months. Conclusion: With proper neuroendovascular training and experience, use of a covered stent is
cost effective and feasible for the treatment of CCFs in under developed countries.
INTRODUCTION
Abnormal communication between the carotid arterial
system and cavernous sinus results in Carotid
Cavernous Fistula [CCF]. Iatrogenic damage [trans-sphenoidal
surgery, glycerol rhizotomy etc] as well as blunt and
penetrating head trauma may lead to direct CCF (1-2).
CCFs not associated with history of trauma are regarded
as spontaneous. Conditions that weaken the Internal
Carotid Artery [ICA] wall can lead to spontaneous CCF.
Predisposing conditions include rupture of carotid
cavernous aneurysm, atherosclerosis, connective tissue
disorders like Ehlers-Danlos syndrome, fibromuscular
dysplasia and pseudoxanthoma elasticum (3-7).
Treatment modalities include conservative approach i.e.
manual compression therapy, surgical management
[carotid ligation], stereotactic radiosurgery and
endovascular management encompassing either or combination
of transarterial and transvenous approaches.
Endovascular transarterial technique employing reconstructive
approach with a covered stent has shown impressive
results. This technique reduces the procedure time and
cost by covering the fistula ostium (8-11). The purpose of
our study was to present our preliminary experience and
feasibility of using a covered stent for CCF treatment.
TECHNIQUE
A 35-year-old man sought medical attention with a few
weeks history of gradually progressive conjunctiva and
episcleral vessel venous congestion, visual blurring and
exophthalmos. His detailed ophthalmologic examination
had earlier shown elevated intraocular pressure. Prior to
the procedure, patient had received coated Aspirin
[75mg/d] and Clopidogrel [75mg/d] for 5 consecutive
days. The procedure was performed under general
anesthesia. After a 6-F guide catheter was positioned in the
distal right carotid artery, the initial diagnostic
angiography showed an indirect right CCF (12). [Barrow’s
Classification – Type D]. The arterial supply to the CCF was from
the capsular branches of the right cavernous ICA [Fig 1]
and a few tiny feeders from the right External Carotid
Artery [ECA] [Fig 2]. Its venous drainage was into the
cavernous sinus and superior ophthalmic vein. Based on
the angiographic findings a vessel reconstructive
approach using a covered stent was planned. Abbott
Vascular Jostent Grafmaster is a low profile stent system
constructed using a sandwich technique with an
ultrathin expandable Polytetrafluoroethylene (PTFE) placed
between the two stainless steel Jostent stents. The
patient was systemically heparinized and serial ACTs were
obtained at regular intervals. A 0.014 mm BMW
microwire was navigated into a distal branch of right middle
cerebral artery. Under road map guidance, a Jostent
Graftmaster 3.5 mm x 16mm was advanced and the
orifice of the fistula was bridged. Immediate post stent
angiography confirmed accurate stent placement but
stent endoleak was noticed. The stent was post dilated to
stop or further reduce the endoleak using UltraSoft
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
5.0x20x153cm angioplasty balloon. Then, Microvention
Headway 17 micro catheter was advanced over BMW
0.014mm microwire and its tip positioned into the right
internal maxillary arterial fistulous feeder branch to the
right CCF. The branch was intentionally sacrificed using
0.5cc of approximately 33% diluted n-butyl
cyanoacrylate [n-BCA] glue. Post procedure angiography
demonstrated complete ob (...truncated)