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Abstract
Objective To describe the treatment of direct high flow carotid–cavernous sinus fistulas (dCCFs) with the double lumen balloon Scepter C.
Materials and methods 7 patients with dCCFs were identified and treated with a double lumen balloon Scepter C. 5 patients had post-traumatic dCCFs and two patients had spontaneous dCCFs due to a ruptured cavernous–carotid aneurysm. The double lumen balloon was used in characterizing the angioarchitecture of the fistula in all patients. The best treatment option was then decided based on the characteristics of the carotid wall tear. Embolization of the cavernous sinus was achieved with coils and injection of Onyx liquid embolic material in three patients and with coils alone in four patients. One patient required stent assisted coiling to reconstruct the internal carotid artery.
Results 7 patients with dCCFs were treated with transarterial embolization. All patients had immediate angiographic and clinical cure. The Scepter C balloon was used for balloon assisted coiling and injection of Onyx liquid embolic material. On follow-up, all patients had clinical symptom resolution.
Conclusions The Scepter C balloon is a useful tool for the transarterial treatment of dCCFs.
- Angiography
- Fistula
- Liquid Embolic Material
- Aneurysm
- Balloon
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Introduction
Direct carotid–cavernous fistulas (dCCFs) can be challenging lesions to treat because of the high flow gradient between the internal carotid artery (ICA) and the cavernous sinus. The clinical presentation of CCFs is a direct consequence of the elevation in intracavernous pressure and inverted flow patterns. Endovascular treatment is the standard approach to close the defect in the ICA wall.1 Transvenous or transarterial approaches are used to treat these lesions and usually aim to close the cavernous sinus through embolization with detachable coils, detachable balloons, or liquid embolic materials.2–4 Alternative endovascular approaches include flow diversion with covered stents and ultimately parent vessel sacrifice.5 ,6
We describe the transarterial balloon assisted embolization of seven dCCFs with the dual lumen balloon microcatheter Scepter C (Microvention, Tustin, California, USA).
Materials and methods
Seven patients with dCCFs were identified and treated with transarterial embolization of the fistula with the dual lumen balloon microcatheter Scepter C. The transarterial approach was the first treatment choice, with the aim of accessing the cavernous sinus for embolization and preserving the ICA. All procedures were performed under general anesthesia with a single plane angiography machine (Allura Xper FD20; Philips, Best, The Netherlands). Before the procedure, patients were receiving dual antiplatelet therapy in case a stent was needed to reconstruct the ICA.
After completion of six vessel digital subtraction angiography (DSA) and a three-dimensional rotational angiogram, a 6 F or 8 F guide catheter was positioned in the cervical segment of the ICA, except for patient No 1 in which the proximal ICA was occluded and the dCCF was accessed through the right vertebral artery and right posterior communicating artery (case example No 1). The dual lumen balloon microcatheter was then navigated through the ICA and positioned in the petrous ICA segment. A standard 014 microwire was used to navigate the Scepter C balloon. The balloon was then inflated and injections of contrast through the Scepter C were performed to characterize the defect in the ICA wall. In this way, we aimed to arrest the high blood flow of the ICA and better visualize the cavernous segment and the fistulous point (figure 1). Before balloon inflation, 3000 units of heparin were administered intravenously to prevent clot formation. The best endovascular treatment was then chosen based on the angioarchitecture of the dCCF. The size and location of the carotid wall defect determined if we used a stent or the Scepter balloon for balloon assisted coiling (BAC). In general, if the arterial tear was large (≥4 mm), we used a stent. Small tears (≤3 mm) were closed with coils and/or Onyx (Covidien, Irvine, California, USA). In some cases, a three-dimensional microcatheter injection angiogram through the Scepter balloon was obtained to better characterize the fistulous point.
Angiography of the cavernous segment of the internal carotid artery with the balloon microcatheter Scepter C. (A) Frontal view of contrast injection through the microcatheter while the balloon is inflated to demonstrate the carotid wall defect (arrows) and opacification of the cavernous sinus (asterisk). The superior ophthalmic vein can be seen draining superiorly. (B) Frontal angiographic view with injection of contrast through the inflated balloon positioned in the internal carotid artery (asterisk), demonstrating arterial outflow (arrow) into the fistulous point and the cavernous sinus. (C) Frontal view of microinjection of contrast through the Scepter balloon, demonstrating the arterial tear with outflow (arrow) into the cavernous sinus (asterisk). In all of these cases, the carotid wall defect was small (≤3 mm), and it was decided to use only coils for embolization of the cavernous sinus.
Clinical presentation, venous outflow, endovascular approach, and follow-up are shown in table 1. Cure was defined as clinical improvement associated with no angiographic evidence of residual or recurrent dCCF.
Clinical characteristics and treatment modalities of seven patients with direct carotid–cavernous fistulas
Case example No 1
A patient in his/her late 10 s presented with right exophthalmos, decreased vision, right VII cranial nerve palsy, headaches, and a right pulsatile bruit. Three years earlier he/she suffered a motor vehicle accident. DSA demonstrated proximal occlusion of the right ICA with distal reconstitution through a complete circle of Willis and external carotid artery anastomoses. A high flow dCCF was observed in the cavernous portion of the right ICA with decreased contrast opacification of the right middle cerebral artery territory due to steal phenomenon (figure 2A, B). The fistula drained through multiple veins: bilateral ophthalmic veins, superior petrosal sinus, basal vein of Rosenthal, and cortical veins. Normal cortical venous outflow was poorly visualized due to venous hypertension. It was decided not to sacrifice the cavernous portion of the ICA to prevent the accidental occlusion of the origin of the posterior communicating artery and the anterior choroidal artery.
Case No 1. (A) Right vertebral artery lateral angiogram demonstrating a high flow direct carotid cavernous fistula. (B) Frontal angiogram of the right vertebral artery demonstrating that most of the flow through the posterior communicating artery is directed towards the fistula with poor visualization of the right middle cerebral artery. (C) A 4×15 mm Scepter C balloon was navigated through the right posterior communicating artery and positioned in the distal internal carotid artery segment. The balloon was inflated (arrow) during embolization of the cavernous sinus with coils and Onyx liquid embolic material to arrest internal carotid artery flow and protect the parent vessel. (D) Visualization of the right middle cerebral artery territory after occlusion of the fistula.
Due to proximal ICA occlusion, a Scepter C 4×15 mm balloon was navigated through the right posterior communicating artery into the cavernous ICA segment. The dual lumen balloon microcatheter was then used to characterize the fistula through microinjections of contrast while the balloon was inflated. Once the fistulous point was identified, the distal tip of the balloon was advanced into the cavernous sinus and used to deploy detachable coils and Onyx (figure 2C). The Scepter balloon was inflated during Onyx injection to prevent reflux of embolic material into the ICA and reconstruction of the ICA wall defect. Final contrast injections demonstrated complete occlusion of the dCCF with visualization of the right middle cerebral artery territory and normalization of cortical venous outflow (figure 2D).
Case example No 2
A patient in his/her late 20 s developed bilateral exophthalmos 6 months before referral. At the time of examination, he/she had decreased bilateral vision, a pronounced right exophthalmos, right orbital pulsatile bruit, and right chemosis. The patient did not have a history of any trauma. CT angiography suggested the presence of a dCCF. A dCCF was identified through DSA and three-dimensional rotational angiography in the left ICA (figure 3A). The dCCF drained mostly through an intercavernous connection into the contralateral right ophthalmic veins. Compartmentalization of the cavernous sinuses may explain why his/her symptoms were more pronounced in the opposite side to the dCCF.7
Case No 2. (A) Left internal carotid artery three-dimensional rotational angiogram demonstrating a large carotid wall defect (arrows) suggestive of a cavernous sinus aneurysm. (B) Post-treatment unsubtracted left internal carotid artery angiogram showing reconstruction of the carotid artery after placement of a stent and embolization of the cavernous sinus with Onyx and coils.
An 8 F access catheter was positioned in the cervical ICA segment. A 4×20 mm Scepter C balloon was then advanced into the cavernous ICA segment. Microcatheter injections through the inflated Scepter balloon were then used to characterize the fistulous point and define the defect of the ICA wall. A wide neck (>4 mm) cavernous segment aneurysm was identified. A Headway 17 microcatheter (Microvention) was used to catheterize the aneurysm and was ‘jailed’ while a 5.5×27 mm LVIS stent (Microvention) was deployed with a Headway 27 microcatheter (Microvention) across the cavernous ICA segment. The cavernous sinus was then coiled through the Headway 17 microcatheter. However, after placement of the last coil, the Headway 17 microcatheter lost access to the cavernous sinus and had to be removed. In order to completely close the fistulous point, the tip of the Scepter C balloon was navigated through the stent and used to inject Onyx into the cavernous sinus while the balloon was inflated inside the stent. In this way, the fistula was closed and the ICA reconstructed with placement of a stent (figure 3B).
Results
Seven patients with dCCFs were treated with direct transarterial embolization. There was one minor complication without clinical significance during the procedure in patient No 7. A large (20 mm×65 cm) cosmos coil (Microvention) detached prematurely during embolization of the cavernous sinus. The coil was not completely positioned in the cavernous sinus and we were not able to recapture it since it knotted with the previously deployed coils. It was elected to leave the coil tail ‘hanging’ in the aortic arch and administer aspirin for 3 months. The distal end of the coil remained in the cavernous sinus and was part of the coil packing. On follow-up, the patient was asymptomatic and the coil did not migrate.
All patients had immediate angiographic and clinical cure. A Scepter C balloon was used in all cases to characterize the fistulous point at the cavernous segment of the ICA. The balloon was also used for BAC and Onyx injection. On follow-up, all patients had clinical resolution of symptoms; one patient refused further imaging. The other six patients had complete angiographic cure on follow-up with DSA.
Discussion
The development of newer endovascular technologies eases the treatment of dCCFs. Each endovascular approach has its advantages and disadvantages. Transarterial embolization with coils or other embolic materials is currently the mainstay endovascular treatment for high flow dCCFs. It is extremely important to characterize the location and dimensions of the ICA tear to choose the best treatment option: coiling, BAC, stent assisted coiling. or even flow diversion. Balloon test occlusion should be performed when there is a possibility of ICA sacrifice. The angioarchitecture of the dCCF may determine the preferred endovascular treatment modality. In the case of a large ICA defect, placement of a stent may not only assist during sinus embolization but may also be used as a vessel reconstruction device. The stent however involves the use of antiplatelet agents and may not be a definite solution in the event of an endoleak into the cavernous sinus due to poor wall apposition, especially with covered stents.8 In this series, a dual lumen balloon microcatheter was an important adjunct in characterizing the dCCF. Microinjection of contrast through the lumen of the inner balloon while the balloon is inflated in the petrous ICA allows proper visualization of the carotid wall defect while the intra-arterial high blood flow of the ICA is contained. This was critical in this case series in choosing the best endovascular approach to close the fistula. Patient No 4, for example, had a ruptured cavernous carotid aneurysm (CCA). Characterization of the <4 mm aneurysm neck favored BAC embolization without placement of a stent. In patient No 5 (case example), we elected to place a stent to reconstruct the defect in the ICA wall due to the presence of a wide neck CCA. Initial injection of contrast through the Scepter balloon demonstrated the presence of a large carotid wall defect.
Interestingly, in this case series, we identified two CCAs as the cause of the dCCF. CCAs usually present with ophthalmologic symptoms and rarely with dCCF.9 dCCFs may occur following CCA treatment with flow diverters, questioning whether flow diversion is even a valid treatment of dCCFs.10
The 0.014 dual lumen balloon Scepter device allows controlled embolization of the cavernous sinus with detachable coils or liquid embolic materials. Embolization is performed with the balloon inflated in the ICA to protect the parent vessel and interrupt the venous outflow through the cavernous sinus. However, the 5 mm length tip of the device has to be advanced and positioned carefully in the cavernous sinus while the balloon portion of the device is used to protect the parent vessel. The balloon should not be inflated through the carotid wall defect as it may further worsen the fistula and damage the ICA. Furthermore, microcatheter injections through the balloon assure correct positioning of the distal tip in the cavernous sinus. Injection of the embolic material has to be performed very slowly and with multiple angiographic controls to avoid reflux into the ICA lumen. We generally used the largest (4×20 mm) Scepter balloon to provide better parent vessel protection, especially while injecting Onyx.
Dual lumen balloon microcatheters have been used in the treatment of dural arteriovenous fistulas.11 The device was used to create an Onyx plug while the balloon was inflated and to perform controlled injection with continuous forward progression of the liquid embolic agent. We used the Scepter balloon to inject Onyx when coil embolization did not completely close the dCCF. The advantage in using Onyx is that it penetrates different venous compartments of the cavernous sinus and efferent veins. We did not experience any cranial nerve neuropathy in embolizing the cavernous sinus.
Balloon assisted coil embolization of traumatic dCCFs has also been described.12 In the case series by Andrade et al, a compliant single lumen balloon was positioned along the carotid tear and used for balloon remodeling of the ICA during coil embolization of the cavernous sinus. A previous series has also reported the use of single balloons for Onyx embolization of dCCFs.13 The balloon was mainly used to protect the parent vessel. The advantage of the dual lumen balloon is that both parent vessel remodeling and embolization can be accomplished with the same device. Moreover, microinjection of contrast through the inflated balloon can be used to characterize the carotid wall defect, which in our case series proved to be extremely useful in choosing the best treatment option. All seven patients were treated in a single session through an arterial approach and with immediate radiological resolution.
A disadvantage of using a balloon is the possible formation of clots but this can be managed with administration of intravenous heparin. This may be a drawback in trauma patients with systemic injuries that cannot be anticoagulated.
In the treatment of dCCF, the dual lumen balloon microcatheter accomplishes a dual function: characterization of the carotid wall defect and protection of the ICA lumen during embolization of the cavernous sinus. Moreover, the balloon can be used to perform a test occlusion in case of vessel sacrifice as an ultimate therapeutic approach. In this case series, the Scepter balloon was a useful tool in characterizing the dCCF and allowing precise and definite treatment.
References
Footnotes
Contributors EAS: study concept and design; acquisition of the data; analysis and interpretation of the data; drafting of the manuscript; administrative, technical, and material support; study supervision; and critical revision of the manuscript for important intellectual content. GA: acquisition of the data. MM-G: critical revision of the manuscript for important intellectual content.
Competing interests None.
Ethics approval The study was approved by the institutional review board.
Provenance and peer review Not commissioned; externally peer reviewed.