Balloon-Assisted Coil and Liquid Embolizing System Repair of Barrow's Type A Carotico-Cavernous Fistula
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.355149
Source of Support: None, Conflict of Interest: None
Key Message: Endovascular treatment of high flow (Barrow's type A) with balloon-assisted coil and liquid embolic agent is a safe and effective option.
Barrow's type A carotid–cavernous fistula (CCF) is a direct, high-flow shunt between the internal carotid artery (ICA) and the cavernous sinus, which usually occurs after trauma or rupture of a carotid–cavernous aneurysm, which usually occurs spontaneously. With the recent advances in endovascular techniques, the treatment of high-flow (Barrow's type A) CCF has evolved several folds. The balloon-assisted coiling and embolization using liquid embolic agents (LEAs) is a very safe, effective, and preferable technique. The use of this technique helps in the efficient placement of coil and LEAs across the fistula.
In this video, we will demonstrate endovascular transarterial repair of Barrow's type A CCF using balloon-assisted coiling and LEA.
A 16-year-old female presented with a history of road traffic accident (RTA) 25 days back followed by a bulging left eye associated with redness, pain, and drooping of the eyelid along with restricted eyeball movement in all directions. An examination of the left eye showed chemosis, proptosis, ptosis, and retro-orbital bruit. The bilateral vision was 6/24 with left total external ophthalmoplegia present.
After taking consent of the patient and her father, the patient was shifted to a digital subtraction angiography (DSA) laboratory. The patient was positioned supine on the table. General anesthesia was given, and painting and draping of the bilateral inguinal region were done for femoral access as a standard. The activated clotting time was maintained between 250 and 300 s during the procedure.
An 8-Fr, 13-cm femoral access sheath (Cook Medical, Bloomington, IN, USA) was used for groin access on the right side. Left ICA diagnostic DSA was taken, which showed high flow of dye into the fistula without any distal flow into the ICA. Therefore, no roadmaps could be made. So, left-side groin access was taken using another 8-Fr, 13-cm femoral access sheath (Cook Medical).
A 6-Fr, 100-cm Envoy guide catheter (Codman Neuro, Raynham, MA, USA) was used to access the right ICA via left femoral artery access. Selective angiography of the right ICA was taken to check for cross flow and to make roadmap of the left ICA. A 6.3-Fr, 105-cm DAC 070 intermediate catheter (Stryker Neurovascular, Fremont, CA, USA) was used to access the left ICA via right femoral artery access. A 150-cm Echelon 14 microcatheter (Medtronic, Dublin, Ireland) with Synchro 200-cm micro-guide wire (Stryker Neurovascular) was used to access the fistula site of the cavernous segment of the left ICA via DAC intermediate catheter. Echelon 14 microcatheter is dimethyl sulfoxide (DMSO) compatible, and therefore can be used to place LEA along with coils. A 150-cm, 4 mm × 10 mm TransForm super-compliant balloon (Stryker Neurovascular) was passed via DAC and inflated across the fistulous opening. Multiple 10 × 30 Target 360 Standard coils (Stryker Neurovascular) were placed in the fistula. This was followed by the placement of LEA, Menox 18 (Meril Life Sciences, Gujarat, India), into the fistula. Occlusion of the fistula was confirmed on postoperative DSA.
Video timeline with audio transcript
02.31–15.55 s: A 16-year-old female presented with history of RTA, followed by left eye bulge, redness, pain, eyelid drooping, and loss of movement since 25 days.
15.55–30.58 s: On examination, left eye chemosis, proptosis, ptosis, and orbital bruit were present. Left-sided third, fourth, and sixth cranial nerve palsy with total external ophthalmoplegia along with bilateral vision of 6/24 was present.
30.52–41.27 s: The patient underwent radiological evaluation, which showed left-sided dilated, tortuous superior ophthalmic vein along with left exophthalmos.
41.28–49.22 s: DSA was done, which confirmed Barrow's type A carotico-cavernous fistula.
50.31–01.04.51 min: Following were the options for treating this patient: 1. manual compression therapy, 2. transvenous embolization, 3. transarterial embolization, 4. surgical ligation and trapping of fistula, and 5. transcavernous repair.
01.04.52–01.26.33 min: We chose transarterial balloon-assisted coil and liquid embolizing material fistula repair due to the following reasons: 1. balloon ensures patency of the parent vessel during coil and glue embolization; 2. dense coil and glue embolization can be performed; and 3. balloon, being super-compliant, can be inflated without injury to the vessel or any risk of vasospasm.
01.26.38–02.11.44 min: The following hardware were required during the intervention: 1. femoral sheath 8 Fr (Cook Medical), 2. guiding catheter 6 Fr Envoy (Codman Neuro), 3. microcatheter Echelon (Medtronic) as this is DMSO compatible, 4. TransForm Occlusion Balloon Catheter (Stryker Neurovascular), 5. liquid embolic system- Menox 18 (Meril Life Sciences India Pvt Ltd), and 6. Target 360 Standard coils (Stryker Neurovascular).
02.11.45–02.28.33 min: After taking proper consent of the patient, the patient was shifted to the DSA lab, where the patient was laid supine and given general anesthesia. Bilateral groin was painted and draped; bilateral femoral artery cannulation was done by the 8-Fr femoral sheath.
02.28.34–02.53.33 min: A 6-Fr, 100-cm Envoy guiding catheter was passed from the left femoral artery and placed in the right ICA for cross flow and giving roadmap of the left ICA. A distal access intermediate catheter was taken up from the right femoral artery and placed in the left ICA at the fistula site, followed by placing an Echelon microcatheter with Synchro micro-guide wire and passing a super-compliant TransForm balloon through it.
02.53.34–03.01.29 min: Biplanar fluoroscopy was taken from the right ICA, which showed cross flow to the other side followed by roadmap formation.
03.01.29–03.09.16 min: Full magnification fluoroscopy from the right ICA was taken with visualization of distal access catheter in the left ICA.
03.09.16–03.17.14 min: Full magnification fluoroscopy from the left ICA was also taken, which showed the fistula site and dilated tortuous ophthalmic vein.
03.18.18–03.35.05 min: Now, through distal access catheter in the left ICA, an Echelon microcatheter with micro-guidewire was passed and the micro-guide wire was advanced further into distal ICA beyond the fistula site, keeping the Echelon microcatheter at the fistula site.
03.35.05–03.46.29 min: Next, a 150-cm, 4 mm × 10 mm TransForm super-compliant balloon was passed via distal access catheter in the left ICA and inflated across the fistula site.
03.46.31–03.57.49 min: After checking the proper functioning of the balloon in situ and microcatheter placement at the fistula site, roadmap was given and packing of fistula was started with multiple coils.
04.01.00–04.07.40 min: Post packing of the fistula with multiple coils, fluoroscopy was taken, which showed that the dye was still passing through the fistula.
04.10.45–04.23.12 min: So, the next step was to fill the fistula site by the liquid embolizing system through Echelon microcatheter, which is DMSO compatible. Note that the balloon was inflated during this process.
04.25.17–04.35.34 min: Fluoroscopy from the left ICA after coil and liquid embolizing system placement showed complete obliteration of the fistula along with patent parent left ICA.
04.35.35–04.44.17 min: Fluoroscopy from the right ICA was taken, and no cross filling could be seen, thus completing the entire procedure with the end desired result.
04.46.53–04.50.27 min: The video of the patient can be seen at 2 months of follow-up.
04.57.04–04.59.45 min: Here are the references.
The patient experienced uneventful recovery and maintained good status at follow-up after 2 months in the form of resolution of left total ophthalmoplegia and improvement of bilateral visual acuity.
Pearls and pitfalls
Since the balloon is super-complaint, it is easy to navigate and inflate in tortuous vessels without any risk of vasospasm. Full coverage of the fistulous site can be done without any damage to the parent vessel. It also prevents the reflux of coils or LEAs back into the parent vessel. Also, there is no need for any anticoagulant in the postoperative period, which increases patient compliance.
Barrow et al. classified CCFs into four types: type A fistulas are direct, high-flow shunts between the ICA and the cavernous sinus, type B fistulas are dural shunts between the meningeal branches of the ICA and the cavernous sinus, type C fistulas are dural shunts between the meningeal branches of the external carotid artery (ECA) and the cavernous sinus, and type D is a dural shunt between the meningeal branches of both the ICA and ECA and the cavernous sinus. In our case, it was the type A fistula due to traumatic injury. Type B, C, and D lesions are low-flow dural fistulas that are spontaneous in origin, often idiopathic, and tend to resolve spontaneously. Although type A CCF could develop spontaneously due to a ruptured aneurysm, most of them develop after trauma especially penetrating craniocervical injuries, where direct trauma to the vessels in the path of a penetrating object is present. The treatment methods for type A CCF can be divided into microsurgery, endovascular surgery, and radiosurgery.
Surgical treatment of the CCF has been attempted since the beginning of the 17th century. In 1973, Parkinson reported a successful direct surgical repair of a direct CCF with preservation of the parent artery. However, the technical difficulty and high mortality of this procedure have led to the search for other better options.
Debrun et al. popularized the detachable balloon technique to treat CCFs and also reported the need for ICA occlusion in up to 20% of type A CCFs. However, despite representing a better alternative to surgery, balloons could not always be used if preservation of the parent artery was desired.
Serbinenko, reported on the use of the detachable balloon method in CCF patients. By this method, the CCF was occluded with the detachable balloon method through the transarterial or transvenous approach. This treatment showed less morbidity and mortality than surgical treatments, so it was used as the first endovascular treatment material. Limitations to the use of balloons include premature detachment, deflation, migration, puncture of the balloon by bony fragments, small size of the fistula, and pseudoaneurysm formation.
Due to the disadvantages of balloons, the use of coil and material embolization became more popularized in the occlusion of CCF. Embolization can be achieved with detachable platinum coils, silk, and LEAs such as n-butyl cyanoacrylate (n-BCA), an ethylene–vinyl alcohol copolymer (EVOH). Advantages of coils include easy access, control, adjustment, deployment, retrieval, and repositioning, in addition to the availability of different thicknesses, sizes, lengths, and shapes. The main disadvantages of coils include slower gradual occlusion of the fistula, incomplete fistula occlusion, compaction, and rarely migration.
Endovascular therapy is considered the first-line and most popular treatment tool for all types of CCF patients., It is divided into the transarterial and transvenous methods according to the vessel approach. It can be done with a LEA or coil embolization, with or without the assistance of a balloon. In our case, the following plans were discussed for the treatment of this patient: 1. manual compression therapy, 2. transvenous embolization, 3. transarterial embolization, 4. surgical ligation and trapping of fistula, and 5. transcavernous repair. We chose transarterial balloon-assisted coil and LEA for fistula occlusion due to the following reasons: 1. the balloon is super-compliant, and therefore can be inflated at tortuous anatomy without the risk of vasospasm, 2. dense coil packing can be performed, and 3. ICA compromise can be prevented.
LEA has the capability of mechanical occlusion without vessel wall adhesion. Its nonadhesive nature decreases the risk of microcatheter retention and allows a slow single injection of an embolic agent with concomitant angiogram checks. LEA has a propensity for retrograde filling of arterial feeders and must be used cautiously to prevent retrograde reflux into the ICA and ECA branches.
Stent deployment allows initial reconstruction of the damaged segment of the parent artery and avoids coil protrusion into the ICA. Covered and flow-diverting stents can also occlude fistula, while preserving ICA patency. The dense coverage of flow-diverting stents protects the ICA during transvenous or transarterial coil insertion and enables endothelial overgrowth of the lacerated arterial segment. However, covered and flow-diverting stents can be difficult to navigate; they are less flexible, more difficult to deploy in intracranial vessels, and can be complicated by periprocedural vasospasm. Also, their placement requires lifelong anticoagulant use, which reduces patient compliance.
With advances and improvisation in the endovascular field, balloon-assisted coil and LEA repair of Barrow's type A fistula is a very safe, effective, and preferable method.
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