Endovascular treatment of spontaneous indirect high flow carotid cavernous fistula with a covered stent.

Pakistan Journal of Neurological Sciences (PJNS), Dec 2014

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.

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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)


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Qasim Bashir, Hina Nabi Ahmed. Endovascular treatment of spontaneous indirect high flow carotid cavernous fistula with a covered stent., Pakistan Journal of Neurological Sciences (PJNS), 2014, Volume 9, Issue 4,