Introduction Coil embolization sacrifice of the internal carotid artery (ICA) is an accepted method for management of a direct carotid cavernous fistula (CCF) when adequate collateral pathways exist. With well packed coils, the expected outcome is irreversible occlusion of the artery and cessation of flow in the fistula. We present a case of an ICA sacrifice, for CCF, that subsequently recanalized and was later salvaged with glue embolization.
Methods A 61-year-old female developed right eye chemosis and proptosis. Workup revealed a direct left ICA CCF. The cavernous left ICA was subsequently embolized with coils from distal to proximal across the fistula, resulting in angiographic occlusion. Her symptoms resolved over several days. The patient resumed Plavix following the procedure for pre-existing coronary artery disease. Two months after the procedure, the patient returned with recurrence of her original symptoms. Repeat angiography showed a recurrence of the fistula fed by backflow from the anterior communicating artery and the small left posterior communicating artery as well as from flow, albeit decreased, through a recanalized embolized left ICA. Attempts to access the distal left ICA to embolize the distal coil pack were unsuccessful. Next, n-BCA embolization of the CCF was performed through the coil mass from the proximal ICA with penetration to the sinus, reestablishing ICA occlusion and cessation of fistula flow into the cavernous sinus. Plavix was withheld following the procedure to assist in maturation of the occlusion.
Results During a clinic visit a few weeks later, the patient reported stable complete resolution of symptoms, including normalization of intraocular pressures.
Conclusion Recanalization of a well coiled internal carotid artery is rare. The use of Plavix following the coil embolization and the persistent backflow from the circle of Willis collaterals may have led to failure of occlusion. Nevertheless, this case shows that n-BCA embolization through the coil mass can salvage a failed sacrifice.