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Endovascular Management Of Carotid-Cavernous Fistula (CCF)

We would wish to present two interesting cases of post traumatic direct carotid cavernous fistula cases which were cured completely using Neurointerventional Radiology Techniques.

Both are young patients who had road traffic accidents following which one of the eye started troubling with increasing redness, decreased vision, inability to completely close the eyes due to proptosis and excessive watering. If untreated such cases may rapidly lose the vision and bulging eye may develop corneal ulceration /infection. Some patients with direct CCF may also develop fatal intracranial bleeds if left untreated.

What exactly happens in carotid cavernous Fistula (CCF)?

Direct carotid-cavernous fistula is an abnormal arteriovenous communication between the carotid artery and the cavernous sinus occurring spontaneously or following head trauma. Traumatic disruption of the vessel wall is the most common etiological factor for direct CCFs.

A CCF allows highly pressurized arterial blood to be transmitted directly into the cavernous sinus and the draining veins, leading to venous hypertension.

What is the treatment of carotid cavernous Fistula (CCF)?

Before the advent of Neurointerventional Techniques, the only way to treat it was through surgical ligation of the injured artery on either of the injured artery. Unfortunately, most of them were not able to tolerate ligation of the main artery supplying the brain and used land up in major stroke which may even kill the patient.

Recent advances in medical technology and emergence of Neurointerventional Radiology is a boon to many neurovascular disorders.

How does Neurointerventional Radiology cure this disease?

Small puncture is done in the groin to enter the femoral artery with a small tube like structure called catheter. Catheter is navigated to the site of injury under the guidance of a specialized machine in Cathlab. We selectively block the tear region without blocking the main artery supplying the brain.
We use detachable balloon or coils or other embolic material or covered stent across the fistula. 

The endovascular approach should be tailored to individual cases according to the type, exact anatomy, and extent of each fistula (Figure 1).

With advances in catheter design, embolic agents, and fluoroscopic imaging equipment, Interventional Neuroendovascular techniques have become the preferred treatment modality for carotid cavernous fistulas and favorable long-term outcomes have been achieved.

Figure 1: Showing CCF and different Neurointervention treatment options

Case 1

CASE 1: Showing CCF on the Left Internal Carotid Artery

CASE 1: Showing balloon Embolization which cured CCF in this case

Case 2

CASE 2: Angiogram demonstrating CCF in the Left Internal Carotid Artery

CASE 2: Endovascular coiling of CCF using platinum coils and balloon

Before and after the procedure

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