Multimodal endovascular treatment for traumatic carotid-cavernous fistula

Objective: To present our experience in treating traumatic carotid-cavernous fistula (TCCF) by multimodal endovascular treatment. Methods: The management of 28 patients with TCCF between January 2004 and October 2012 in our hospital was retrospectively analyzed. According to imaging charateristics, 24 cases were categorized into Type I, 3 Type II and 1 Type III. Totally 30 endovascular treatments were performed: Type I TCCFs were obliterated via transvenous approach (7/25), or transarterial approach (18/25) including 6 by detachable balloon occlusion, 6 by microcoil embolization, 3 by Hyperglide balloon-assisted coil embolization and 3 by a combination of detachable balloon and coil embolization. Two patients were treated with closure of internal carotid artery (ICA). Type II TCCFs were treated with transvenous embolotherapy(2/3) or carotid artery compression therapy (1/3). The Type III patient underwent detachable balloon embolization. Results: Immediate postoperative angiography showed recovery in 26 cases. One recurrent TCCF was found 2 weeks after detachable balloon embolization, and then reobliterated by transarterial coils. Reexamination found balloon deflation and fistula recanalization in 1 patient one month after combination of detachable balloons and coil embolization, which was cured by a second treatment via transvenous approach. The immediate angiography revealed residual blood flow in 4 patients. Among them, 2 patients with delayed symptoms at follow-up needed a second treatment, 1 patient recovered after carotid artery compression therapy, and the remaining patient's symptoms disappeared on digital subtraction angiography at five-month follow-up. CT angiography revealed anterior communicating artery aneurysm in the patient who was treated with closure of ICA 4 years later. Conclusion: According to results of images, characteristics of the fistula and type of drainage, proper treatment approach and embolic material can maximally heal pathological changes, retain the ipsilateral ICA patency and reduce long-term complications.