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The use of a covered stent graft for obliteration of high-flow carotid cavernous fistula presenting with life-threatening epistaxis
  1. J S Kalia1,
  2. T Niu1,
  3. O O Zaidat1,2,3
  1. 1Department of Neurology, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin, USA
  2. 2Department of Neurosurgery, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin, USA
  3. 3Department of Radiology, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin, USA
  1. Correspondence to Dr O O Zaidat, Associate Professor of Neurology, Radiology and Neurosurgery, Director, Neurointerventional Program, Medical College of Wisconsin and Froedtert Hospital West, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA; szaidat{at}


Background We present a rare complication of trans-sphenoidal adenectomy (TSA) for pituitary macroadenoma: carotid cavernous fistula (CCF) that was treated with endovascular therapy. The incidence of internal carotid artery (ICA) injury following TSA is 1% and may spontaneously heal by packing and rarely manifest as symptomatic CCF/aneurysm. Treatment of post-TSA CCF may be challenging due to the breach of nasal floor and may be prone to recurrence.

Presentation/intervention Uncontrolled intra-operative bleeding during a TSA led to an emergent angiogram to show slow-flow left CCF. Due to clinical deterioration with nasal bleeding, angiography was repeated after 4 h; the fistula had transformed into high flow with significant increase in size, and was therefore embolized using stent-assisted coiling. The fistula recanalized in a month with massive epistaxis and was re-treated using a covered stent graft.

Conclusion This case represents several unique learning points: (1) CCF as a complication of TSA due to close anatomical proximity; (2) the role of endovascular management post-TSA complication; (3) stent-assisted coil embolization of high-flow fistula with moderate ICA laceration; (4) recanalization of CCF causing massive epistaxis; (5) rare use of covered stent graft stent in distal intracranial circulation maintaining integrity and patency of ICA; (6) long-term results after covered stent graft with no in-stent restenosis.

  • Trans-sphenoidal adenectomy (TSA)
  • carotid cavernous fistula (CCF)
  • pituitary macroadenoma
  • coil embolization
  • Wingspan stent
  • iatrogenic
  • endovascular coiling
  • epistaxis
  • Jomed stent
  • graft repair
  • brain
  • malformation
  • intervention
  • stent

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  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Medical College of Wisconsin; IRB: Institutional Review Board.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; not externally peer reviewed.