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Case series
Flow diverters as a scaffold for treating direct carotid cavernous fistulas
  1. Jacob F Baranoski1,
  2. Andrew F Ducruet2,
  3. Colin J Przbylowski1,
  4. Rami O Almefty1,
  5. Dale Ding1,
  6. Joshua S Catapano1,
  7. Scott Brigeman1,
  8. Vance L Fredrickson1,
  9. Daniel D Cavalcanti1,
  10. Felipe C Albuquerque3
  1. 1 Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  2. 2 Barrow Neurological Institute, Phoenix, Arizona, USA
  3. 3 Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  1. Correspondence to Dr Felipe C Albuquerque, Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA; felipe.albuquerque{at}


Background Direct carotid–cavernous sinus fistulas (dCCFs) are high flow arteriovenous shunts between the internal carotid artery and the cavernous sinus. Recently, we have used the pipeline embolization device (PED) to treat dCCFs.

Methods We describe our experience treating patients with dCCFs in whom the PED was placed as the primary treatment modality.

Results Five patients with dCCFs were treated with PEDs deployed in the ipsilateral internal carotid artery spanning the fistula. All patients also underwent either adjunctive transvenous or transarterial embolization. The PED served both as the primary treatment modality and as a scaffold that facilitated safe and efficacious transvenous embolysate administration by altering the flow dynamics through the fistula and providing a physical barrier that protected the internal carotid artery. No intraoperative or perioperative complications occurred. One of the five patients exhibited complete angiographic resolution of the fistula immediately after the procedure. The remaining four patients experienced complete obliteration of the fistula without additional treatment, which suggests that the PED induced alteration promoted thrombosis of the fistula. Therefore, 100% of patients in this series exhibited complete and durable obliteration of the fistula and complete resolution of symptoms following treatment.

Conclusions We believe that use of the PED to treat dCCFs may be a safe and efficacious strategy that facilitates parent vessel protection during transvenous embolization. Furthermore, the flow alterations induced by the PED may promote thrombosis of incompletely occluded fistulas. This is the largest reported series of non-iatrogenic dCCFs treated with use of the PED as the primary initial treatment strategy.

  • arteriovenous fistula
  • direct carotid-cavernous fistulas (dCCFs)
  • flow diversion
  • flow-diverting devices
  • flow-diverting stent
  • Onyx
  • pipeline embolization device (PED)
  • scaffold
  • transvenous embolization

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  • Contributors Primary writing of the text, manuscript preparation, data collection, and interpretation and approval of the text: JFB, AD, and FCA. Assistance with manuscript preparation and critical revision, data collection and interpretation, and approval of the text: CJP, ROA, DD, JSC, SB, VLF, and DDC. Project design: JFB, AD, and FCA. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: JFB, AD, CJP, ROA, DD, JSC, SB, VLF, DDC, and FCA.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests AD: Consulting agreement with Medtronic (pipeline embolization device certification proctor).

  • Ethics approval Institutional review board approval was obtained for this project (PHX-18-500-335-73-12).

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

  • Data sharing statement There are no additional data to share.

  • Correction notice Since this article was first published online, the initial F has been added to Dr Ducruet’s name.

  • Patient consent for publication Not required.