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      Endovascular treatment of carotid-cavernous vascular lesions Translated title: Tratamento endovascular das lesões vasculares carótido-cavernosas

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          Abstract

          ABSTRACT Objective: to evaluate the endovascular treatment of vascular lesions of the cavernous segment of the internal carotidartery (ICA) performed at our institution. Methods: we conducted a descriptive, retrospective and prospective study of patients with aneurysms of the cavernous portion of the ICA or with direct carotid-cavernous fistulas (dCCF) undergoing endovascular treatment. Results: we included 26 patients with intracavernous aneurysms and ten with dCCF. All aneurysms were treated with ICA occlusion. Those with dCCF were treated with occlusion in seven cases and with selective fistula occlusion in the remaining three. There was improvement of pain and ocular proptosis in all patients with dCCF. In patients with intracavernous aneurysms, the incidence of retro-orbital pain fell from 84.6% to 30.8% after treatment. The endovascular treatment decreased the dysfunction of affected cranial nerves in both groups, especially the oculomotor one. Conclusion: the endovascular treatment significantly improved the symptoms in the patients studied, especially those related to pain and oculomotor nerve dysfunction.

          Translated abstract

          RESUMO Objetivo: avaliar o tratamento endovascular de lesões vasculares da artéria carótida interna (ACI), segmento cavernoso, realizado na Santa Casa de São Paulo. Métodos: estudo descritivo, retrospectivo e prospectivo, de pacientes com aneurisma da porção cavernosa da ACI ou com fístulas carótido-cavernosas diretas (FCCd) submetidos a tratamento endovascular. Resultados: foram incluídos 26 pacientes com aneurismas intracavernosos e dez com FCCd. Todos os aneurismas foram tratados com oclusão da ACI. Os com FCCd foram tratados com oclusão, em sete casos, e com oclusão seletiva da fístula nos outros três. Houve melhora da dor e proptose ocular em todos os pacientes com FCCd. Nos pacientes com aneurisma intracavernoso, a incidência de dor retro-orbitária caiu de 84,6% para 30,8% após o tratamento. Após o tratamento endovascular houve uma melhora importante da disfunção de nervos cranianos afetados em ambos os grupos, sobretudo no nervo oculomotor. Conclusão: o tratamento endovascular trouxe melhora para os pacientes deste estudo, especialmente nos critérios dor e acometimento do nervo oculomotor.

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          Carotid-cavernous fistulas.

          Jason Ellis, Hannah Goldstein, E Connolly … (2012)
          Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.
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            Direct microsurgical repair of intracavernous vascular lesions.

            Vinko Dolenc (1983)
            Three patients with aneurysms of the internal carotid artery (ICA) situated in the cavernous sinus (CS), and four patients with traumatic carotid-cavernous fistulas (CCF's) were treated by direct surgical approach. Two aneurysms were clipped, whereas the third (a giant aneurysm) was resected and the wall of the ICA reconstructed using interrupted sutures. In two CCF's, the shunt was excluded during reconstruction of the ICA wall by suturing. In the remaining two patients with CCF's, the shunt was excluded by clipping. The CS was attacked directly using a combination of three different techniques: the pterional, the subtemporal, and the petrosal approach. The ICA in its whole course through the CS, as well as the third through the sixth cranial nerves, were exposed. No special measures, such as hypotension, hypothermia, extracorporeal circulation and cardiac arrest, or dehydration, were taken during surgery. The aim of the direct approach to the CS was to exclude the aneurysm and/or the CCF and preserve the ICA patency. In all seven cases operated on, the lesions were excluded without inflicting any additional damage to the third through sixth cranial nerves, and in five cases carotid patency was preserved.
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              Endovascular techniques for treatment of carotid-cavernous fistula.

              J Gemmete, Vivek Gandhi, S Ansari (2009)
              Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous communications in the cavernous sinus. Direct CCFs result from a tear in the intracavernous carotid artery. Indirect CCFs generally occur spontaneously and cause more subtle signs. Direct CCFs, which typically have high flow, usually present with ocular-orbital venous congestive features and cephalic bruit. Indirect CCFs, which typically have low flow, present with similar but more muted clinical features. Direct CCFs are always treated with endovascular methods. The goal is to occlude the fistula but preserve the patency of the internal carotid artery (ICA). Agents include detachable coils or liquid embolic agents delivered transarterially or transvenously. Arterial porous or covered stents are often used adjunctively. In rare cases, the ICA must be occluded. Indirect CCFs are only treated if symptoms are intractable or intolerable or if vision is threatened. The goal is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus. The traditional approach has been transarterial embolization with liquid agents, particularly n-butyl cyanoacrylate (n-BCA). However, the multiplicity of arterial feeders and the low success rate in occluding indirect CCFs by the arterial route has led to a preference for transvenous embolization, most commonly via the inferior petrosal sinus. If that sinus is impassable, alternative routes include the pterygoid venous plexus, superior petrosal sinus, facial vein, or ophthalmic veins. The cavernous sinus is occluded with coils, liquid embolic agents, or both. The use of ethylene vinyl alcohol copolymer (Onyx), an agent that may be superior to n-BCA because it may allow better distal fistula penetration. However, more safety and efficacy data must be accumulated. When experienced interventionalists are involved, the success rate for closing direct fistulas is 85%-99% and for closing indirect fistulas is 70%-78%. Serious complications are relatively infrequent.
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                Author and article information

                Contributors
                GUILHERME BRASILEIRO DE AGUIAR: Role: ND
                JOÃO MIGUEL SILVA: Role: ND
                ALINE LARIESSY PAIVA: Role: ND
                MAURÍCIO JORY: Role: ND
                MARIO LUIZ CONTI: Role: ND
                JOSÉ CARLOS VEIGA: Role: ND
                Journal
                Journal ID (publisher-id): rcbc
                Title: Revista do Colégio Brasileiro de Cirurgiões
                Abbreviated Title: Rev. Col. Bras. Cir.
                Publisher: Colégio Brasileiro de Cirurgiões (Rio de Janeiro, RJ, Brazil )
                ISSN (Print): 0100-6991
                ISSN (Electronic): 1809-4546
                Publication date (Print and electronic): February 2017
                Volume: 44
                Issue: 1
                Pages: 46-53
                Affiliations
                [1] Sao Paulo Sao Paulo orgnameSão Paulo Holy Home orgdiv1Faculty of Medical Sciences orgdiv2Department of Surgery Brazil
                Article
                Publisher ID: S0100-69912017000100046
                DOI: 10.1590/0100-69912017001007
                SO-VID: a986f5f6-668a-4105-8152-73401bf21e1e
                License:

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                Date accepted : 22 September 2016
                Date received : 09 August 2016
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 30, Pages: 8
                Product

                SciELO Brazil


                Keywords: Carotid-Cavernous Sinus Fistula,Embolization, Therapeutic,Carotid Artery Injuries,Fístula Carotidocavernosa,Embolização Terapêutica,Lesões das Artérias Carótidas
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                Keywords: Carotid-Cavernous Sinus Fistula, Embolization, Therapeutic, Carotid Artery Injuries, Fístula Carotidocavernosa, Embolização Terapêutica, Lesões das Artérias Carótidas

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