Endovascular therapy of direct dural carotid cavernous fistulas – A therapy assessment study including long-term follow-up patient interviews

Autoři: Lorenz Ertl aff001;  Hartmut Brückmann aff001;  Maximilian Patzig aff001;  Gunther Fesl aff001
Působiště autorů: Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany aff001;  Radiologie Augsburg-Friedberg ÜBAG, Augsburg, Germany aff002
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0223488



Endovascular embolization nowadays is a well-established treatment option for direct carotid cavernous fistulas (dCCF, Barrow Type A). There are many publications on the complication and success rates of this method. However, little is known on the patients´ opinion on the treatment result after several years. We report on this issue also including the “pioneer patients” treated almost two decades ago.


We retrospectively reviewed the records of all patient (n = 25) with a more than 24 months follow-up interval after endovascular treatment of a dCCF at our institution from 01/1999 to 08/2018. We determined primary therapy success, complication rate, state of the fistula in the last imaging follow-up and quoted the patient’s subjective perception of the long-term treatment success using a standardized interview form.


Occlusion rate in the last imaging follow up was 96% (24/25) with a complication rate of 8% (2/25). The response rate on our interview request was 96% (24/25) with a rate of considered feedback of 84% (21/25 patients). Duration of our observation interval for the patient reported outcome was 143 months / 11 years (median, range: 35–226 m / 2–18 y). Most of them (21/25, 84%) felt they benefited from the treatment.


Endovascular supply of dCCF is a highly effective treatment method leading to a sustainable therapy success with long-lasting stable subjective benefit even to our “pioneer patients” treated almost two decades ago.

Klíčová slova:

Aneurysms – Carotid arteries – Eyes – Fistulas – Head injury – Tinnitus


1. Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg. 1985;62: 248–256. doi: 10.3171/jns.1985.62.2.0248 3968564

2. Lewis AI, Tomsick TA, Tew JMJ. Management of 100 consecutive direct carotid-cavernous fistulas: results of treatment with detachable balloons. Neurosurgery. 1995;36: 239–44; discussion 244–245. doi: 10.1227/00006123-199502000-00001 7731502

3. Chi CT, Nguyen D, Duc VT, Chau HH, Son VT. Direct traumatic carotid cavernous fistula: angiographic classification and treatment strategies. Study of 172 cases. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci. 2014;20: 461–475. doi: 10.15274/INR-2014-10020 25207910

4. Ramalingaiah AH, Prasad C, Sabharwal PS, Saini J, Pandey P. Transarterial treatment of direct carotico-cavernous fistulas with coils and Onyx. Neuroradiology. 2013;55: 1213–1220. doi: 10.1007/s00234-013-1224-z 23828324

5. Pashapour A, Mohammadian R, Salehpour F, Sharifipour E, Mansourizade R, Mahdavifard A, et al. Long-Term Endovascular Treatment Outcome of 46 Patients with Cavernous Sinus Dural Arteriovenous Fistulas Presenting with Ophthalmic Symptoms. A Non-Controlled Trial with Clinical and Angiographic Follow-up. Neuroradiol J. 2014;27: 461–470. doi: 10.15274/NRJ-2014-10079 25196621

6. Jung K-H, Kwon BJ, Chu K, Noh Y, Lee S-T, Cho Y-D, et al. Clinical and angiographic factors related to the prognosis of cavernous sinus dural arteriovenous fistula. Neuroradiology. 2011;53: 983–992. doi: 10.1007/s00234-010-0805-3 21161199

7. De Renzis A, Nappini S, Consoli A, Renieri L, Limbucci N, Rosi A, et al. Balloon-assisted coiling of the cavernous sinus to treat direct carotid cavernous fistula. A single center experience of 13 consecutive patients. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci. 2013;19: 344–352. doi: 10.1177/159101991301900312 24070084

8. Bink A, Goller K, Luchtenberg M, Neumann-Haefelin T, Dutzmann S, Zanella F, et al. Long-term outcome after coil embolization of cavernous sinus arteriovenous fistulas. AJNR Am J Neuroradiol. 2010;31: 1216–1221. doi: 10.3174/ajnr.A2040 20299427

9. Kiyosue H, Hori Y, Okahara M, Tanoue S, Sagara Y, Matsumoto S, et al. Treatment of intracranial dural arteriovenous fistulas: current strategies based on location and hemodynamics, and alternative techniques of transcatheter embolization. Radiogr Rev Publ Radiol Soc N Am Inc. 2004;24: 1637–1653. doi: 10.1148/rg.246045026 15537974

10. Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg. 1974;41: 125–145. doi: 10.3171/jns.1974.41.2.0125 4841872

11. Williams ZR. Carotid-Cavernous Fistulae: A Review of Clinical Presentation, Therapeutic Options, and Visual Prognosis. Int Ophthalmol Clin. 2018;58: 271–294. doi: 10.1097/IIO.0000000000000215 29517654

12. Gao B-L, Zhao W, Xu G-P. The development of a de novo indirect carotid-cavernous fistula after successful occlusion of bilateral direct carotid-cavernous fistulas. J Trauma. 2009;66: E28–31. doi: 10.1097/TA.0b013e3181238d28 19204498

13. Liang W, Xiaofeng Y, Weiguo L, Wusi Q, Gang S, Xuesheng Z. Traumatic carotid cavernous fistula accompanying basilar skull fracture: a study on the incidence of traumatic carotid cavernous fistula in the patients with basilar skull fracture and the prognostic analysis about traumatic carotid cavernous fistula. J Trauma. 2007;63: 1014–1020; discussion 1020. doi: 10.1097/TA.0b013e318154c9fb 17993945

14. Arteriovenous fistulae of the CNS. AJNR Am J Neuroradiol. 2001;22: S22–25. 11686070

15. Luo C-B, Teng MM-H, Chang F-C, Guo W-Y, Chang C-Y. Multiple intracranial carotid injuries: pitfalls in diagnosis by angiography and principles of endovascular treatment. J Trauma. 2009;67: 1327–1332. doi: 10.1097/TA.0b013e31818ba44a 20009686

16. Hanneken AM, Miller NR, Debrun GM, Nauta HJ. Treatment of carotid-cavernous sinus fistulas using a detachable balloon catheter through the superior ophthalmic vein. Arch Ophthalmol Chic Ill 1960. 1989;107: 87–92. doi: 10.1001/archopht.1989.01070010089033 2910291

17. Cogbill TH, Moore EE, Meissner M, Fischer RP, Hoyt DB, Morris JA, et al. The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma. 1994;37: 473–479. doi: 10.1097/00005373-199409000-00024 8083912

18. Lewis AI, Tomsick TA, Tew JMJ, Lawless MA. Long-term results in direct carotid-cavernous fistulas after treatment with detachable balloons. J Neurosurg. 1996;84: 400–404. doi: 10.3171/jns.1996.84.3.0400 8609550

19. Norman D, Newton TH, Edwards MS, DeCaprio V. Carotid-cavernous fistula: closure with detachable silicone balloons. Radiology. 1983;149: 149–157. doi: 10.1148/radiology.149.1.6611922 6611922

20. Korkmazer B, Kocak B, Tureci E, Islak C, Kocer N, Kizilkilic O. Endovascular treatment of carotid cavernous sinus fistula: A systematic review. World J Radiol. 2013;5: 143–155. doi: 10.4329/wjr.v5.i4.143 23671750

21. Morton RP, Tariq F, Levitt MR, Nerva JD, Mossa-Basha M, Sekhar LN, et al. Radiographic and clinical outcomes in cavernous carotid fistula with special focus on alternative transvenous access techniques. J Clin Neurosci Off J Neurosurg Soc Australas. 2015;22: 859–864. doi: 10.1016/j.jocn.2014.11.006 25682541

22. Elhammady MS, Wolfe SQ, Farhat H, Moftakhar R, Aziz-Sultan MA. Onyx embolization of carotid-cavernous fistulas. J Neurosurg. 2010;112: 589–594. doi: 10.3171/2009.6.JNS09132 19591548

23. Elhammady MS, Peterson EC, Aziz-Sultan MA. Onyx embolization of a carotid cavernous fistula via direct transorbital puncture. J Neurosurg. 2011;114: 129–132. doi: 10.3171/2010.1.JNS091433 20136392

24. Cheng K-M, Chan C-M, Cheung Y-L. Transvenous embolisation of dural carotid-cavernous fistulas by multiple venous routes: a series of 27 cases. Acta Neurochir (Wien). 2003;145: 17–29. doi: 10.1007/s00701-002-1013-7 12545258

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2019 Číslo 10
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