Alternative Routes for Treating Carotid-cavernous Fistula Using an Intraarterial Balloon-Assisted Technique

 

Object: Endovascular therapy has become the primary treatment modality for carotid-cavernous fistulas (CCFs) offering a 90 to 100% cure rate with a low rate of complications. Multiple approaches have been employed to treat carotid-cavernous fistulas (CCFs). The transvenous approach has become a popular and effective route. Especially that the complex anatomy of the cavernous sinus provides multiple routes. The first-line approach is the inferior petrosal sinus providing a straightforward short course, additionally, the superior petrosal sinus, basilar plexus, pterygoid plexus, superior ophthalmic vein (SOV), or inferior ophthalmic vein provides alternative options. Onyx is a valuable tool in today’s endovascular armamentarium, and when employed in combination with coils and balloons its efficiency is multiplied. The authors share their experience with different routes used to reach the cavernous sinus for treating the pathology. The transvenous routes include internal jugular vein (IJV) to the IPS to the cavernous sinus, or an orbital cutdown for a direct puncture of the SOV to the cavernous sinus, or IJV then facial vein then angular vein then SOV reaching the cavernous sinus and lastly rarely a transarterial approach particularly in type A CCF. The author report the outcome of 50 cases of CCF treated with Onyx using a balloon-assisted technique and assess its outcomes and safety.

Methods: A retrospective review of a prospectively maintained database for CCFs treated with onyx using a balloon-assisted technique was performed.

Results: Fifty patients treated between July 2009 and July 2018 at the authors' institution. The compliant balloon placed in the internal carotid artery (ICA) assisted in clear visualization of the fistulous point, served as an abutment for coils, protected from inadvertent arterial embolization, and prevented Onyx and coils from obscuring the ICA during embolization. The routes accessed were 30 subjects through SOV, ten subjects through IJV-IPS, five subjects through an IJV-Facial vein, and five subjects transarterially. All fistulas utterly obliterated at the end of the procedure, and no balloon-related complications noted in any of the cases. Complications noted were 30% developed transient worsening of EOM deficit with improvement in 80% of cases at 6 months of follow-up, 20% developed a peek of intra-ocular pressure the first 24 hours treated by either ocular drops or bedside iridotomy. Six months radiological follow-up showed complete obliteration of the CCF in 99% of cases.

Conclusion: Reconstruction of the carotid-cavernous fistula navigating using various approaches provides safer superior outcomes. Moreover, the employment of a balloon-assisted Onyx embolization of CCFs offers a powerful combination that prevents inadvertent migration of the embolic material into the arterial system, facilitates visualization of the ICA, and serves as an abutment for coils deployed in the cavernous sinus through the fistulous point. Despite adding another layer of technical complexity, an intraarterial balloon can provide valuable assistance in the treatment of CCFs.