1251. Use of Flow-Diverting Devices as a Scaffold and Primary Treatment Modality for Direct Carotid-Cavernous Fistulas

Authors: Jacob Francis Baranoski, MD; Colin Przybylowski, MD; Rami Almefty, MD; Dale Ding, MD; Andrew Ducruet, MD; Felipe Albuquerque, MD (Phoenix, AZ)

Introduction: Successful treatment of direct carotid-cavernous sinus fistulas (dCCFs) requires complete obliteration of the shunt while preserving ICA patency. Traditionally, endovascular treatment options for dCCFs involved detachable balloons, coils, and/or liquid embolysates. More recently, we have utilized flow-diverting devices (FDDs) to achieve safe and effective occlusion of dCCFs. Methods: We describe a series of 5 patients with dCCFs treated utilizing FDDs as the primary treatment modality. Results: Five patients with dCCFs underwent endovascular intervention using a FDD. All five also underwent adjunctive transvenous (4) or transarterial (1) treatment. For the 4 patients who received transvenous intervention, the FDD facilitated safe and efficacious treatment by both altering the flow dynamics through the fistula and protecting the parent ICA. Indeed, a transarterial balloon was utilized for additional ICA protection in only 2 of these patients. No intraoperative or perioperative complications occurred. One of the 5 patients exhibited complete angiographic resolution of their fistula immediately following treatment. Interestingly, the 4 patients with incomplete obliteration of their fistula at the time of treatment were found to have complete resolution of their fistulas on follow-up angiograms without additional treatment, suggesting that the FDD-induced alteration in flow may have contributed to thrombosis of the fistula. Therefore, 100% of patients in this series had complete obliteration of their fistula following treatment. On last angiographic follow-up (median 40months), 100% had continued complete obliteration of their fistula. All patients experienced complete resolution of their symptoms following treatment. Conclusion: We believe that the upfront use of FDDs for the treatment of dCCFs is a safe and efficacious strategy that facilitates parent vessel protection during transvenous treatment. Further, the flow alterations induced by the FDD may promote thrombosis of incompletely occluded fistulas. This is the largest reported series of dCCFs treated utilizing FDDs as the primary initial treatment strategy.