Patient reported long-term outcome after endovascular therapy of indirect dural carotid cavernous fistulas

Clinical Profile and Management Outcomes among Patients with Carotid-Cavernous Fistula

Background

A carotid-cavernous sinus fistula (CCF) is an abnormal communication between the internal carotid artery and/or the external carotid artery and the cavernous sinus. There is a paucity of information on the ophthalmic outcomes of endovascular treatment for CCF in the Philippines.

Objectives

This study aimed to describe the clinical experience of CCF in our institution in order to further our understanding of the disease. This study described the demographic profile, risk factors, and clinical features of patients with CCF, and compared the data of patients according to the type of CCF. The study discussed the changes in clinical features over time in CCF patients who chose not to undergo endovascular treatment. The study also discussed the clinical outcomes of CCF patients who underwent endovascular treatment and compared the clinical outcomes to CCF patients who did not undergo endovascular treatment.

Methods

A retrospective cohort study design was performed using a medical record review of patients clinically diagnosed with CCF from January 2011 to June 2019.

Results

One hundred twenty medical records of patients diagnosed with CCF were included. Based on angiographic findings, patients were grouped according to type of CCF, with 86 patients in Group 1 or Direct CCF, 23 patients in Group 2 or Indirect CCF, and 11 patients in Group 3 or Mixed type of CCF. The patients were also grouped according to treatment, with 109 patients in Group A, or patients who did not undergo endovascular treatment, and 11 patients in Group B, or patients who underwent endovascular treatment. There was a male predominance in CCF, most occurring in the age range of 26 to 35 years. Risk factors for CCF were trauma and hypertension. Clinical features included the presence of blurring of vision, proptosis, corkscrewing of conjunctival vessels, extraocular movement limitation, diplopia, audible bruit, elevated intraocular pressure, and pulsation. Findings on Computed Tomography scan included dilated superior ophthalmic vein, proptosis, and enlarged extraocular muscles. Direct CCF (Group 1) occurred mostly in males, with mean age of 39.1 years, and with trauma as the major risk factor. Indirect CCF (Group 2) occurred mostly in females, with mean age of 52.1 years, and with hypertension as the major risk factor. Regardless of the type of CCF, patients who did not undergo endovascular treatment can exhibit spontaneous improvement or worsening of clinical features. Patients who underwent endovascular treatment generally had favorable clinical outcomes, manifesting as either improvement or no worsening of features. There were minimal ophthalmic complications associated with treatment.

Conclusion

Endovascular treatment is safe and effective in the improvement of visual acuity, corkscrewing of conjunctival vessels, amount of proptosis, extraocular movement limitation, diplopia, and presence of audible bruit.

Radiation Dose and Fluoroscopy Time of Endovascular Coil Embolization in Patients with Carotid Cavernous Fistulas

Carotid cavernous fistulas (CCFs) are abnormal connections between the cavernous sinus and the internal and/or external carotid artery. Endovascular therapy is the gold standard treatment. In the current retrospective single-center study we report detailed dosimetrics of all patients with CCFs treated by endovascular coil embolization between January 2012 and August 2021. Procedural and dosimetric data were compared between direct and indirect fistulas according to Barrow et al., and different DSA protocol groups. The local diagnostic reference level (DRL) was defined as the 3rd quartile of the dose distribution. In total, thirty patients met the study criteria. The local DRL was 376.2 Gy cm². The procedural dose area product (DAP) (p = 0.03) and the number of implanted coils (p = 0.02) were significantly lower in direct fistulas. The median values for fluoroscopy time (FT) (p = 0.08) and number of DSA acquisitions (p = 0.84) were not significantly different between groups. There was a significantly positive correlation between DAP and FT (p = 0.003). The application of a dedicated low-dose protocol yielded a 32.6% DAP reduction. In conclusion, this study provides novel DRLs for endovascular CCF treatment using detachable coils. The data presented in this work might be used to establish new specific DRLs.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas. Institutional Series, Systematic Review and Meta-Analysis

Purpose

Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs.

Methods

PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center.

Results

A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5–96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82–12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001).

Conclusion

A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents.