Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

Background: Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described. Methods: We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent. Results: After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed. Conclusion: FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.

Vacuum-assisted mechanical thrombectomy in extensively occlusive thrombosis of dialysis arteriovenous grafts with indigo system.

PURPOSE: To present a selected series of extensively occlusive thrombosis of arteriovenous graft treated with the Penumbra's Indigo System. MATERIALS AND METHODS: Ten patients with acute (within 72 h) extensively occlusive thrombosis of arteriovenous graft (mean extension = 30.1 (range = 15-45) cm) were treated at our institution with the Indigo System. Of the 10 cases, thrombosis was extended to venous outflow in 7 cases and to both arterial inflow and venous outflow in 3 cases. RESULTS: Both anatomic and clinical success were achieved in 8 of the 10 procedures (80.0%). In the 2 cases of technical failure, the patients underwent surgical thrombectomy with the finding of arteriovenous graft exhaustion, which was then replaced. The 6-month primary patency, primary-assisted patency, and secondary patency rates were 37.5% (3/8), 50.0% (4/8), and 62.5% (5/8). We reported 2 complications (one minor and one major adverse event). CONCLUSION: Percutaneous mechanical thrombectomy aspiration with Indigo System is a relatively safe and effective procedure and can be used even in extensively thrombosed arteriovenous graft.

Efficacy of Primary Stent-Graft Placement in the Treatment of Vascular Access Graft Outflow Tract Stenosis.

PURPOSE: The aim of this study is to present our personal experience using covered nitinol stent-graft in the treatment of outflow tract stenosis of arteriovenous grafts (AVGs) for hemodialysis access. MATERIALS AND METHODS: Between May 2015 and October 2017, we retrospectively evaluated 36 (24 males, 12 females; mean age: 65.6 years) patients with AVGs on hemodialysis who underwent percutaneous angioplasty followed by endovascular stent-graft deployment for the treatment of stenosis of the venous outflow of the AVG. Indication for treatment included early restenosis (<3 months after previous percutaneous transluminal angioplasty [PTA]), long stenosis (stenoses >50% extending for a length >5 cm), and recoil of the stenosis after PTA performed with a noncompliant high-pressure balloon. Of 36 patients, 27 (75%) required surgical thrombectomy prior to endovascular procedure. Technical success, clinical success, primary and secondary patency, and safety were evaluated. RESULTS: Technical success was 100%, and clinical success was 94.4%. Primary patency was 94.4%, 72.2%, 63%, 45.9%, and 45.9% at 1, 3, 6, 12, and 18 months (average: 215 days, range: 9-653 days); secondary patency was 94.4% and 86.1% at 1 and 3 months; 80.4% at 6, 12, and 18 months; and 53.6% at 24 months (average: 276.8 days, range: 9-744 days). No deaths were registered. CONCLUSIONS: In selected cases, the use of stent-graft represents an effective and safe solution for the treatment of stenotic complications of the venous outflow of AVGs, even in the setting of access thrombosis.