Stand-alone transarterial flow diversion for treatment of carotid cavernous fistulas

Objective: Carotid-cavernous fistulas (CCFs) are rare arteriovenous communications allowing blood to flow from the carotid artery into the cavernous sinus. Although currently coil and/or liquid embolization remain the preferred treatment methods for CCFs, flow diverters (FD) stents represent a viable alternative to traditional embolization techniques. This study explores both the technical aspects and rationale behind using FD stents as a stand-alone treatment approach for CCFs. Methods: The study includes records of 7 patients with CCFs treated at two comprehensive stroke centers from 2019 to 2023. Patients treated with FD stenting in conjunction with coil and/or liquid embolization were excluded from the study. Results: Five patients were diagnosed with direct CCFs and 2 patients with indirect CCFs. Six patients were treated with the Surpass Evolve FD stent and 1 patient with the Pipeline FD stent. DSA follow-up was performed for an average duration of 14.4 months following FD placement. Complete fistula obliteration with no residual shunting was observed in all patients. Furthermore, all patients experienced a complete resolution of symptoms following treatment. Conclusions: The authors' experiences suggest the efficacy and safety of FD stenting as a stand-alone treatment option for CCFs. Compared to embolization, FD stents can better preserve the parent vessel and promote healing with less associated mass effect. Despite being a retrospective self-assessment with a relatively small sample size, to the authors' knowledge, this study represents the largest individual case series of patients with CCF treated with stand-alone FD stenting.