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Use of Pipeline Embolization Devices for treatment of a direct carotid-cavernous fistula

  • Technical Note - Vascular
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

The use of minimally porous endoluminal devices (MPEDs) such as the Pipeline Embolization Device (PED) has been described for the treatment of brain aneurysms. The benefit of using MPEDs to assist embolization of a direct high-flow carotid cavernous fistula resulting from a ruptured cavernous carotid artery aneurysm is not well documented.

Methods

We describe our experience with deploying a tailored multidevice PED construct across the cavernous internal carotid artery (ICA) wall defect in combination with transarterial coil embolization using the “jailed microcatheter” technique.

Results

A 59-year-old woman presented with acute left-sided ophthalmoplegia. Diagnostic cerebral angiography demonstrated a ruptured giant cavernous carotid aneurysm with fistulous outflow via the ipsilateral left superior ophthalmic vein and into the pterygoid venous plexi bilaterally. Via the Marksman microcatheter, a total of three PEDs measuring 4.5 mm × 18 mm, 4.5 mm × 20 mm, and 4.75 mm × 16 mm were telescoped within the ICA across the aneurysm neck. Coiling of the aneurysm fundus and cavernous sinus via the “jailed” Rapidtransit microcatheter was subsequently achieved. A 2-year follow-up digital subtraction angiography (DSA) demonstrated stable obliteration of the aneurysm and the fistula, coincident with complete resolution of the patient’s symptoms.

Conclusions

Based on our long-term clinical and angiographic results, we advocate that the presented method be a valid treatment option for selected cases.

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Conflicts of interest

Maksim Shapiro and Tibor Becske are Pipeline proctors and consultants for Covidien.

All other authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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The patient has consented to submission of this technical note to the journal.

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Author notes

    Authors and Affiliations

    1. Department of Neurological Surgery, New York University School of Medicine, New York, NY, USA

      E. Nossek, D. Zumofen, M. B. Potts, O. Tanweer & Howard A. Riina

    2. Department of Neurointerventional Radiology, New York University School of Medicine, New York, NY, USA

      E. Nossek, D. Zumofen, E. Raz, M. B. Potts, K. G. Desousa, M. Shapiro, T. Becske & Howard A. Riina

    3. Neurochirurgie und Interventionelle Neuroradiologie, Unversitaetsspital Basel, Basel, Switzerland

      D. Zumofen

    4. United Nations International School, New York, NY, USA

      E. Nelson

    Authors
    1. E. Nossek
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    2. D. Zumofen
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    3. E. Nelson
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    4. E. Raz
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    5. M. B. Potts
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    6. K. G. Desousa
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    7. O. Tanweer
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    8. M. Shapiro
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    9. T. Becske
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    10. Howard A. Riina
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    Corresponding author

    Correspondence to Howard A. Riina.

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    Comments

    Direct carotid-cavernous fistulas have been treated by transarterial embolization using detachable balloons. Currently, the detachable balloons are not available commercially in many countries for several reasons. Instead of balloons, the coils are mainly used for the treatment of direct carotid-cavernous fistulas. However, the coil is much more expensive than balloons, and it is sometimes difficult to get complete occlusion of the fistulas by using coils only.

    The authors demonstrated a new method to treat direct carotid-cavernous fistulas using Pipeline Embolization Devices. This technique will be an alternative for the endovascular treatment of direct carotid-cavernous fistulas. The necessary number of PEDs and packing density of coils to get complete occlusion of the fistula without any complications are issues in the future.

    Kenji Sugiu

    Okayama, Japan

    E. Nossek and D. Zumofen contributed equally to this work

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    Nossek, E., Zumofen, D., Nelson, E. et al. Use of Pipeline Embolization Devices for treatment of a direct carotid-cavernous fistula. Acta Neurochir 157, 1125–1130 (2015). https://doi.org/10.1007/s00701-015-2446-0

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    • DOI: https://doi.org/10.1007/s00701-015-2446-0

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