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Table of Contents    
Year : 2011  |  Volume : 59  |  Issue : 6  |  Page : 895-898

Covered coronary stent grafts as a treatment option for carotid-cavernous fistulas: Our initial experience

Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

Date of Submission19-Jul-2011
Date of Decision14-Aug-2011
Date of Acceptance05-Sep-2011
Date of Web Publication2-Jan-2012

Correspondence Address:
Mathew Cherian
Department of Radiology, Kovai Medical Center and Hospital, Avinashi Road, Coimbatore, Tamil Nadu - 641 014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.91373

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 » Abstract 

Treatment of Type 1 carotid-cavernous fistula (CCF) is complex and endovascular stent grafting is proving to be an excellent technique not only in successful treatment of fistula but also preserving patency of parent artery. We describe our initial experience in the use of covered coronary stent grafts in the treatment of three patients with Type 1 post-traumatic CCF. All patients were successfully treated with placement of stent grafts. Immediate closure of fistula was achieved in all the three patients. One patient developed partial in-stent thrombosis. In this patient antiplatelet therapy had to be stopped as he developed a small intracerebral hematoma post procedure. Subsequently, he was restarted on antiplatelets and recovered completely. Except for this no other complication was observed. Covered stent grafts may be the procedure of choice for treatment of post-traumatic Type 1 CCF especially in young patients with favorable anatomy.

Keywords: Carotid-cavernous fistula, covered stent grafts, stent thrombosis

How to cite this article:
Kalyanpur TM, Narsinghpura K, Yadav M, Mehta P, Paul K, Cherian M. Covered coronary stent grafts as a treatment option for carotid-cavernous fistulas: Our initial experience. Neurol India 2011;59:895-8

How to cite this URL:
Kalyanpur TM, Narsinghpura K, Yadav M, Mehta P, Paul K, Cherian M. Covered coronary stent grafts as a treatment option for carotid-cavernous fistulas: Our initial experience. Neurol India [serial online] 2011 [cited 2020 Feb 19];59:895-8. Available from:

 » Introduction Top

Type 1 carotid-cavernous fistula (CCF) is a type of arterio-venous fistula, wherein an abnormal direct fistulous communication exists between the cavernous portion of the intracranial carotid artery (ICA) and cavernous sinus. The most common cause is trauma. [1] The clinical manifests include: Progressive pulsatile exophthalmos, chemosis, retroorbital pain, subjective and objective bruit, and cranial nerve palsies. Diversion of intracranial blood flow can result in neurological deficits. The definitive management of any fistula is to obliterate the fistulous communication which not only improves intracranial blood flow but also reduces venous pressure responsible for ophthalmologic symptoms. Surgical options include ligation of the parent artery, described in early 1809. [2] With the advent of endovascular procedures, radical surgeries are becoming less frequent. Serbinenko [3] introduced the technique of using detachable latex balloons, which was popularized by Debrun and colleagues. [4] Although both surgery and endovascular treatment with detachable balloons were well-established treatments of CCF, these techniques had a fair share of success and complications. The major limitations of these procedures have been sacrifice of ICA in certain cases, [5] balloon rupture on the table, delayed deflation with recurrence of symptoms, and occlusion of vessel in case of distal migration. [6],[7],[8] Alternative ways to treat CCF with preservation of the parent artery are continuously being sought and they include detachable coils and cyanoacrylate glue. Stent-assisted coil placement had been introduced as a technique to cure CCF with good results. [9] Stent grafts were first reported as a treatment option for CCF only recently in 2006 [10] and are gaining importance. We present our experience in three patients with post-traumatic CCF treated with covered stents with mean follow-up of 18 months.

 » Case Reports Top

Case 1

A 28-year-old male presented to us three months after sustaining head injury, with chemosis and painful proptosis of left eye with preserved eye movements. Hand-held Doppler revealed a bruit over the left orbit. Cerebral angiography showed a Type 1 CCF between the C3 portion of the cavernous portion of the ICA and the cavernous sinus with drainage into the ophthalmic vein [Figure 1]. He was placed on dual antiplatelet therapy for five days prior to the procedure The carotid artery at the site of the fistula measured 4.5 mm, and a 7F-long (Cook) sheath was positioned in the cervical common carotid artery through which a 6 F Neuron Penumbra catheter was placed in the petro-cavernous junction of the ICA. An SL 10 micro catheter was navigated across the fistula into a branch of the middle cerebral artery. The microcatheter was exchanged for an extra-support 300-cm coronary wire. A Graftmaster stent graft (4 × 12 mm) was tracked over the guidewire and placed across the fistula. It was further dilated up to 6 mm since there was residual flow into the fistula after dilatation with 4-mm and 5-mm balloons. Post-procedure angiography showed closure of the CCF and preserved ICA [Figure 2]. At six months follow-up the patient was asymptomatic. Antiplatelet therapy was discontinued after six months.
Figure 1: Case 1- Left ICA injection showing a Type I fistula between the C3 portion of the ICA and the cavernous sinus, with evidence of flow steal. Venous drainage is through ophthalmic vein and inferior petrosal sinus

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Figure 2: Case 1-6F Guiding catheter (Neuron) placed at the petrocavernous junction of the left ICA, through which a 40x12 mm Graftmaster stent was positioned across the fistula over a 300-cm coronary guidewire. Post-procedure angiography showing preserved ICA, no residual fistula and flowre-established

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Case 2

A 46-year-old male sustained head injury in a road traffic accident. He developed hemiparesis and facial palsy 20 days after the trauma. On examination he had proptosis with chemosis. Computed tomography (CT) scan of the head showed a dilated tortuous ophthalmic vein. Cerebral angiography revealed a Type 1 CCF from the left ICA draining into the ophthalmic vein. The patient was treated with a 4 × 16 mm Graftmaster stent graft which was introduced using a triaxial technique as described before [Figure 3]. There was immediate improvement in the clinical picture [Figure 4]. Post-procedure CT scan showed a small hematoma in the left posterior parietal lobe possibly secondary to a small perforation by the guidewire as the stent graft was being tracked over-the-wire. However, the patient did not have neurological deficit and antiplatelet therapy was withheld for 48 h. A follow-up CT scan showed filling defects within the stent graft suggestive of thrombus and he was restarted on antiplatelet therapy. Patient was readmitted six weeks later for headache and a repeat CT showed fresh hematoma on the opposite side. He was managed conservatively and later discharged on only clopidogrel. Six month after the procedure the patient continues to asymptomatic with no further problems.
Figure 3: Case 2 - Pre-procedure angiography showing Type I CCF from the left ICA. A 0.014-inch guidewire negotiated across the site of the fistula into the Middle Cerebral Artery branch. Balloon expandable stent graft deployed at the site of the fistula. Post-procedure angiography showing no filling of the fistula

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Figure 4: Case 2- Pre and post-procedure clinical photographs showing dramatic resolution of the proptosis and chemosis of the left eye

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Case 3

A 34-year-old male presented with chemosis and proptosis of right eye one month following trauma. A post-contrast CT scan showed features consistent with a Type 1 CCF from the right ICA. Using the above-mentioned technique, the patient was successfully treated using a Graftmaster stent graft [Figure 5]. The patient had an uneventful recovery [Figure 6].
Figure 5: Case 3- Angiography performed using the 6F Neuron catheter confirmed the site of Type I fistula which was seen to drain into the ophthalmic veins. Post-procedure right ICA angiography shows good result with normally filling distal vessels

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Figure 6: Case 3- Pre and post-procedure clinical photos showing near complete resolution of the symptoms

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 » Discussion Top

Treatment of posttraumatic CCF can be extremely difficult. Even in the best of hands both detachable balloons and coils can result in parent artery occlusion. With the insertion of coils directly into the cavernous sinus, there is a potential risk of coil dislodgment into the ICA, especially if the defect is large. [10] In addition, detachable coils can turn out to be an extremely expensive option. Detachable balloons on the other hand are unreliable and are known to deflate prematurely resulting in recurrence and at times even in diversion of blood into intracranial veins which can result in bleeding.

The concept of using stent grafts in the management of CCFs is not new. However, the last few years have shown better guiding catheters enabling us to position the stent grafts in the cavernous segment of the carotid artery. Stent grafts were primarily manufactured for use in coronary arteries and are not very trackable. We found the triaxial system, where a neuron catheter was placed coaxially into a long sheath, extremely helpful in navigating the stent graft into the correct position, and hence was the choice in all the three patients. The long sheath provides the support that the stent would require. However, it is the neuron catheter that provides a pathway for the stent graft. The neuron catheter has a proximal shaft which is a steel braid-reinforced 6F proximal support zone with a distal platinum coil flexible zone. The distal zone being flexible and hydrophilic allows for optimal trackability and higher placement of the catheter. In addition an extra-support coronary wire is a mandatory requirement to straighten the carotid siphon.

Stent grafts are known to be thrombogenic and thus it is important that all patients are started on dual antiplatelet therapy at least five days prior to the procedure and this combination is continued for at least six months. It is ideal to check platelet function prior to the procedure. However, in all our patients this was not done since good filling of the fistula was seen from the opposite side. One of the patients had minor intracranial hemorrhage probably related to dual antiplatelet therapy.

The reasons why we were successful in all the three patients probably are the triaxial technique and young age of the patients. The cavernous segment of the carotid artery has a much tighter curve when the patient is above 40 and in these patients it would be extremely difficult to track the stent graft.

Among the three choices that are available today in the management of CCF stent grafts have been given the least importance. In our experience of three patients we have achieved a good result in all and we believe that it would be a good option in the management of CCF, especially when the patient is young.

 » References Top

1.Archondakis E, Pero G, Valvassori L, Boccardi E, Scialfa G. Angiographic follow-up of traumatic carotid cavernous fistulas treated with endovascular stent graft placement. AJNR Am J Neuroradiol 2007;28:342-7.  Back to cited text no. 1
2.Francis PM, Khayata MH, Zabramski JM, Spetzler RF. Carotid cavernous fistulae: Part I: Presentation and features. In: Carter LP, Spetzler RF, Hamilton MG, Editors. Neurovascular surgery. USA: McGraw-Hill Inc; 1995. p. 1049-59.  Back to cited text no. 2
3.Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 1974;41:125-45.  Back to cited text no. 3
4.Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Kervel Y, et al. Experimental approach to the treatment of carotid-cavernous fistulas with an inflatable and isolated balloon. Neuroradiology 1975;9:9-12.  Back to cited text no. 4
5.Fages-Caravaca EM, Tembl-Ferrairo JI, Lago-Martin A, Vázquez-Añón V, Mainar E. Direct carotidcavernous fistulas: Endovascular treatment using a detachable balloon. Rev Neurol 2001;33:533-6.  Back to cited text no. 5
6.Debrun GM, Vinuela F, Fox AJ, Davis KR, Ahn HS. Indications for treatment and classification of 132 carotid-cavernous fistulas. Neurosurgery 1988;22:285-9.  Back to cited text no. 6
7.Lewis AI, Tomsick TA, Tew JM, Davis KR, Ahn HS. Management of 100 consecutive direct carotid-cavernous fistulas: Results of treatment with detachable balloons. Neurosurgery 1995;36:239-45.  Back to cited text no. 7
8.Halbach VV, Higashida RT, Barnwell SL, Dowd CF, Hieshima GB. Transarterial platinum coil embolization of carotid-cavernous fistulas. AJNR Am J Neuroradiol 1991;12:429-33  Back to cited text no. 8
9.Moron FE, Klucznik RP, Mawad ME, Strother CM. Endovascular treatment of high-flow carotid cavernous fistulas by stent-assisted coil placement. AJNR Am J Neuroradiol 2005;26:1399-404.  Back to cited text no. 9
10.Madan A, Mujic A, Daniels K, Hunn A, Liddell J, Rosenfeld JV. Traumatic carotid artery-cavernous sinus fistula treated with a covered stent. J Neurosurg 2006;104:969-73.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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