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Transarterial coil embolization of a carotid-cavernous fistula which occurred during stent angioplasty

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Abstract

Intracranial endovascular procedures are less invasive and relatively safe; however, these procedures do carry a risk of complications, such as thromboembolization, arterial injury, and vessel occlusion. We present a case of carotid-cavernous fistula development secondary to injury of the cavernous segment of the internal carotid artery (ICA) during stent angioplasty and its treatment by transarterial coil embolization. Probable causes of this complication and its treatment method are discussed. To the best of our knowledge, this is the first report of such a case.

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Authors and Affiliations

  1. Department of Neurosurgery, Holy Family Hospital, The Catholic University of Korea, Seoul, Korea

    Won Ki Yoon, Young Woo Kim, Seong Rhim Kim, Ik Seong Park, Sang Don Kim & Min Woo Baik

Authors
  1. Won Ki Yoon
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  2. Young Woo Kim
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  3. Seong Rhim Kim
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  4. Ik Seong Park
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  5. Sang Don Kim
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  6. Min Woo Baik
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Corresponding author

Correspondence to Min Woo Baik.

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Comment

This paper reports an imaginative and technically challenging case describing an endovascular approach in which a high-flow CCF was closed by using detachable coils that were introduced into the cavernous sinus from a venous and an arterial approach, while preserving the ICA and restoring the normal hemispheric ICA flow. Most interestingly, none of this was originally planned, but rather executed “à la Carte” to sequentially solve ensuing problems. However, contrary to the authors claim, there have been several case reports of patients with direct CCFs as a result of iatrogenic internal carotid artery laceration associated with intracranial angioplasty [1–3] or after transsphenoidal surgery for pituitary adenoma [4, 5] treated by stent placement and stent-assisted coiling placement.

After the analysis of the morphology of the fistula, we believe that the complication derived from both stent-related problems (the use of a coronary stent, stent oversize and stiffness, which may result in arterial rupture) and patient-related problems (calcification, plaque rupture and tortuousness of ICA due to age). As one might conclude in this case, identification of appropriate candidates for treatment remains a challenge. Collaterally, would the authors systematically advise a brain CT angiogram as a pre-treatment work-up tool in older patients to find out ICA calcifications?

Additionally, an accurate measure of the size of the ICA is essential, because this allows a correct choice of the size of the stent to be deployed. It is known that a high-pressure inflation is often performed in coronary stent placement to optimize the stent apposition to the arterial wall. However, in the case of intracranial vessels, the potential risk of rupture from high-pressure inflations may be greater due to a lack of surrounding supportive tissue in the subarachnoid space. But, considering the risk of vessel-wall rupture, the maximal pressure in the balloon may not be as important as the rate of inflation. The question of what constitutes a safe inflation pressure and rate in the intracranial vessels is an important one. Equally, with balloon-expandable stents, as used in this patient, adequate predilatation of the vessel may be crucial. Predilatation prepares a route of atraumatic passage for the balloon-mounted stent and reduces the resistance to expansion of the stent during inflation. Vascular biomechanics are important to define differences between cerebral arteries and extracranial vessels and partly explain the technical challenges facing cerebral artery revascularization compared with revascularization of coronary arteries. In terms of a safe high-flow fistula embolisation, it may be important to consider the use of a balloon that could be insufflated inside the stent to prevent coils from herniating through open cells of the stent into the parent artery. These are issues that are open to discussion.

Finally, the authors could have commented on the newly available covered, or self-expanding stents as a conceptual idea to surmount these complications in the future, and perhaps compare this case with their center’s experience with the new intracranial devices. We agree that covered stents may be technically difficult to deliver, especially in elderly patients with tortuous vessels, as it was the case here.

Overall, this paper raises the question of the intracranial use of coronary stent. Stents are very useful devices that allow initial reconstruction of the damaged segment of the ICA and then controlled coil deposition into the cavernous sinus in CCF. Balloon-expandable coronary stents used “off-label” or with modified coronary devices in approval studies showed a wide range of complication rates and variable short-term follow-up results and raised doubts concerning the clinical effectiveness of the treatment [6–10].

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Oscar L. Alves

Portugal

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Yoon, W.K., Kim, Y.W., Kim, S.R. et al. Transarterial coil embolization of a carotid-cavernous fistula which occurred during stent angioplasty. Acta Neurochir 151, 849–854 (2009). https://doi.org/10.1007/s00701-009-0351-0

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