Fistulas carótido cavernosa / Carotid Cavernous Fistulas

Las fistulas carotido-cavernosas son patologías vasculares relativamente infrecuentes que tiene una etiología de mayor frecuencia traumática que espontanea. Su diagnóstico no siempre es sencillo y requiere de conocer la patología para poder tener la sospecha clínica y poder brindar solución de manera rápida y minimizar secuelas. El tratamiento de las fistulas ha mejorado con el tiempo y con el advenimiento de la cirugía endovascular, con esto se han ido descubriendo mejores accesos y mecanismos para tratarlo, como lo es el abordaje por la vena oftálmica superior. Sin embargo esto no siempre es posible debido a la variaciones anatómicas que en ella se encuentran, pero cuando se logra tiene resultado cosméticos y funcionales muy adecuados.

Carotid-cavernous fistulas are relatively uncommon vascular pathologies that have a traumatic etiology mostly spontaneous. Diagnosis is not always easy and requires knowledge of pathology to clinical suspicion and have to provide a solution quickly minimizing the consequences. The treatment of the fistulas has improved with the time and with the advent of the surgery endovascular, with this have been discovered and improved access mechanisms as is the boarding across the ophthalmic top vein. Nevertheless, this not always is possible due to the anatomical variations that in her they find, but when it is achieved, there are obtained cosmetic and functional very suitable results.

Endovascular Graft-Stent Placement for Treatment of Traumatic Carotid Cavernous Fistulas

Detachable balloon-based endovascular fistula occlusion is a widely accepted treatment for traumatic carotid cavernous fistulas (CCF). However, more recently coils have been used to obliterate the lesion, especially in case detachable balloon is not available. We failed balloon-assisted coil embolization for CCF because of large fistulas and herniation of coil loops into the parent artery. The authors describe our experiences of balloonexpandable graft-stents to treat CCF, and place emphasis on arterial wall reconstruction. Three traumatic CCF patients were treated using a graft-stent with/without coils, and underwent angiographic follow-up to evaluate the patency of the internal carotid artery (ICA). In all cases, symptoms related to CCF regressed after stent deployment and did not recur during follow-up. Follow-up angiography revealed good patency of the ICA in all patients. Graft-stents should be considered as an alternative means of treating CCF and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.

Combined surgery and endovascular treatment of complicated traumatic carotid-cavernous fistulas: Results and illustrated cases.

Objective: To review Siriraj Hospital’s experiences with direct surgical treatment of complicated traumatic carotid-cavernous fistulas (CCFs) in the context of multidisciplinary approach. Methods: This study is a retrospective review of complicated direct carotid cavernous fistulas (CCFs) that had opened surgery after failure of detachable balloon embolization. Data were collected from medical records, radio-angiographic records, and follow-up results of combinations of treatment. Results: From 1993- April 2003, we have total 25 cases of combined surgery and endovascular treatment of traumatic carotid-cavernous fistulas (CCFs). Causes of unsuccessful balloon embolization are small-hole fistula, deflation of the balloon, difficult position of fistula, false aneurysm, risk of intracavernous internal carotid artery (ICA) occlusion, and tortuosity of ICA and draining veins. Various procedures were performed and all patients have good results with completed resolution of clinical triad symptoms. On follow-up cerebral angiography of 16 patients that received cavernous sinus packing, we could preserve the patency of ICA in 8 patients but 5 patients had thrombosis of ICA without ischemic events. In 3 patients, an operation to occlude the ICA was performed after failure of cavernus sinus packing. Conclusions: The standard treatment of carotid cavernous fistula is endovascular balloon embolization. When the endovascular treatment fails, surgical packing of cavernous sinus is immediately considered an alternative way to cure the CCFs and to offer additional technique to help increase the patency of ICA.

Endovascular Treatment of Bilateral Spontaneous Carotid-cavernous Fistulas

The authors report a case of a 46-year-old woman with bilateral spontaneous carotid-cavernous fistulas(CCFs). The patient was treated by endovascular management via multiple trans-arterial and trans-venous routes. Left side CCF was embolized completely via surgically exposed superior ophthalmic vein route. Right side lesion was tried by multi-modality endovascular trajectories and achieved partial thrombosis by trans-arterial approach. The follow-up angiogram two months after the last embolization showed a complete bilateral elimination of fistulas. Embolization of bilateral complex CCFs can be achieved by multiple trans-arterial and trans-venous routes, including direct surgical exposure of superior ophthalmic vein.

Embolization of Carotid Cavernous Fistulas Using “Flying Kite” Technique and Detachable Balloon / 中国医师杂志

Objective To evaluate the effect of “flying kite” technique and detachable balloon on embolization of carotid-cavernous fistulas (CCF). Methods 9 cases of CCF were treated by using“flying kite”technique, and 6 cases of CCF were treated by using detachable balloon. Results In “flying kite” treatment group, 8 cases were completely cured, and 1 case was partly cured. In detachable ballon treatment group, all 6 cases were completely cured once. Conclusion The“flying kite”technique was simple method for embolization of CCF, which didn't need special instruments and materials, and was easy to use in the basic hospitals, but it could obstruct carotid artery and lead to CCF recurrence. The embolization of CCF by using detachable balloon had a higher curative rate and recurred rarely, but it needed special instruments and skills. Detachable balloon embolization of CCF is a reliable method for the treatment of CCF. [