Neuropsychiatric Presentation in Indirect Carotid-Cavernous Fistula: A Case Report.

Carotid-cavernous fistula (CCF) is a rare sight and potentially life-threatening disorder arising from an abnormal connection between the carotid artery and the cavernous sinus. It can be classified into direct or indirect according to different arteriovenous shunts. Direct CCF usually has dramatic ocular presentations, whereas indirect CCF has a more insidious course and may be associated with neurologic symptoms in posteriorly draining fistulas. A 61-year-old gentleman presented with five days history of altered behavior and double vision preceding a bulging left eye. Ocular examination showed left eye proptosis, generalized chemosis, total ophthalmoplegia, and raised intra-ocular pressure. Computed tomography angiography (CTA) brain and orbit demonstrated dilated superior ophthalmic vein (SOV) with communication to a tortuous cavernous sinus suggestive of carotid-cavernous fistula (CCF). Digital subtraction angiography (DSA) eventually confirmed the presence of indirect communication between branches of the bilateral external carotid artery (ECA) and left cavernous sinus, which is a type C indirect CCF according to the Barrow classification. Total embolization of left CCF was successfully achieved via transvenous access. A marked reduction of proptosis and intra-ocular pressure was noted following the procedure. Although rare, neuropsychiatric presentation could be a possible presentation of CCF, and treating physicians should be aware of it. A high index of suspicion and prompt diagnosis is crucial in managing this sight and life-threatening condition. Early intervention can improve the prognosis of patients.

Pinch-off syndrome from a chemoport catheter successfully managed with endovascular retrieval.

INTRODUCTION AND IMPORTANCE: A totally implantable venous access device (TIVAD), also referred to as 'chemoport', is frequently used for oncology patients. Chemoport insertion via the subclavian vein access may compress the catheter between the first rib and the clavicle, resulting in pinch-off syndrome (POS). The sequela includes catheter transection and subsequent embolization. It is a rare complication with incidence reported to be 1.1-5.0% and can lead to a devastating outcomes. CASE PRESENTATION: 50-year-old male had his chemoport inserted for adjuvant chemotherapy 3 years ago. During the removal, remaining half of the distal catheter was not found. There was no difficulties during the removal. Chest xray revealed that the fractured catheter had embolized to the right ventricle. Further history taking, he did experienced occasional palpitation and chest discomfort for the past six months. Electrocardiogram and cardiac enzymes were normal. Urgent removal of the fractured catheter via the percutaneous endovascular approach, under fluoroscopic guidance by an experience interventional radiologist was done. The procedure was successful without any complication. Patient made an uneventful recovery. He was discharged the following day, and was well during his 3rd month follow up. CONCLUSION: Early detection and preventive measures can be done to prevent pinch-off syndrome. Unrecognized POS can result in fatal complications such as cardiac arrhythmia and septic embolization. Retrieval via the percutaneous endovascular approach provide excellent outcome in the case of embolized fractured catheter.