Flow Diverters as Useful Adjunct to Traditional Endovascular Techniques in Treatment of Direct Carotid-Cavernous Fistulas

Background Direct carotid-cavernous sinus fistulas (CCFs) are high-flow arteriovenous shunts that are typically the result of a severe head injury. The endovascular treatment of these lesions includes the use of detachable balloons, coils, liquid embolic agents, and covered stents. To minimize the chance of treatment failure and subsequent complications, endoluminal reconstruction using a flow-diverting stent may be added to the treatment construct. Methods We present 3 cases and review the existing literature. Results Three patients with direct traumatic CCFs were treated with either coils, coils and Onyx, or a detachable balloon, followed by placement of a flow-diverting stent for endoluminal reconstruction. All 3 cases had complete angiographic occlusion of the CCFs and recovered clinically. No complications were observed. Conclusions We believe that endovascular coil or balloon occlusion of the fistula from either a transvenous or transarterial approach followed by flow diversion may be an appropriate treatment for direct CCFs. This addition of a flow diverter may facilitate endothelialization of the injury to the internal carotid artery.