Use of Solitaire (TM) retrievable stent-assisted coiling technique for endovascular treatment of post-traumatic direct carotid cavernous fistula

Pleasecitethisarticleinpressas:FatihNasO,etal.UseofSolitaireTM_{retrievablestent-assistedcoilingtechniquefor} endovasculartreatmentofpost-traumaticdirectcarotidcavernousfistula.DiagnosticandInterventionalImaging(2016), http://dx.doi.org/10.1016/j.diii.2016.03.002

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DiagnosticandInterventionalImaging(2016)xxx,xxx—xxx

LETTER

TO

THE

EDITOR

/Vascular

and

interventional

radiology

Use

of

Solitaire

_retrievable

stent-assisted

coiling

technique

for

endovascular

treatment

of

post-traumatic

direct

carotid

cavernous

fistula

Keywords Directcarotidcavernousfistula;Retrievable stent-assistedcoilingtechnique;SolitaireTM_stent Deareditor,

Major endovascular techniques for direct carotid cav-ernousfistula(DCCF)treatmentincludetransarterialand/or transvenous use of balloons, detachable coils, and liquid embolicagentsandrarely,bareorcoatedstents[1].Herein, retrievablestent-assistedcoilingtechniquewasappliedto apatientwithpost-traumaticDCCFandafistulatractinthe leftinternal carotidartery(ICA).Acompletelyretrievable SolitaireTM _{stent (Ev3, Irvine, CA, USA) was used to} pre-ventcoilmigrationandotherpotentialcomplicationsofcoil embolization.

A 26-year-oldman,involved ina carcrash2.5 months ago,wasadmittedtoourhospitalwithproptosisand red-nessin hisleft eye. Selectivecerebral digital subtraction angiography(DSA)showedaruptureintheclinoidsegment oftheleftICAcommunicatingwiththesuperiorophthalmic vein. Findings suggested a post-traumatic DCCF (Fig. 1a). Endovascularinterventionwasplanned.Followingthe induc-tion of general anesthesia, systemic heparinization was performed with an activated clotting time of 200—300s. A 6F 80cm guiding catheter (Neuron MAX) was placed in proximitytotheleftICAthroughtherightcommonfemoral artery.A6Fintroducerwasinsertedthroughtheleft com-monfemoral vein, anda 6Fguiding catheter (Envoy)was advancedtowardstheinternaljugularvein.Usingtheright jugularpath,amicrocatheter(Excelsior1018)wasadvanced fromtheinferiorpetrosalsinustothecavernoussinus.The microcathetercouldnotbeadvancedtothefistulasegment and appropriate coil embolization could not be obtained throughthe venous sitebecause of strictures at the cav-ernous sinus. Using the arterial path, an Excelsior 1018

microcatheterwasadvancedfromthecarotidcavernous fis-tulalocationtowardsthecavernoussinus.Amicrocatheter (ProwlerSelectPlus)wasplacedintotheleftmiddle cere-bral artery. A 4mm×20mm SolitaireTM _{stent was placed} into the carotid cavernous fistula region in the ICA. A 16mm×50cmcoil(TargetXL360◦Standard)wasusedatthe beginningoftheembolization.Coilsofvarioussizes(Target 360◦ and3D GuglielmiDetachable)wereusedfor therest (Fig.1b—d).The SolitaireTM _{stentwasextracted fromthe} fistulasiteaftercoilembolization.However,thecavernous sinuscouldnotbeembolizedtotallybecauseofitsocclusive segments(Fig.2a).Thepatientwasdischargedfromthe hos-pitalwithwealthonpostoperativeday1andadministered oralmethylprednisolone(32mg/day)for15 days.Eye prob-lemscompletelyregressedonemonthlater.DSAdisplayed totalclosureofthefistula(Fig.2b).

Coilsandembolicagentsliken-butylcyanoacrylateglue andethylenevinylalcoholcopolymer(Onyx®_)canbeused for endovascular treatment of carotid cavernous fistulas [2,3].Theseagentscanbeusedseparatelyorincombination by adopting transarterial and/or transvenous approaches [3].Nadarajahetal.treatedaDCCF withaflow-diverting stent [1]. We applied an endovascular technique using a SolitaireTM _{stent for endovascular treatment of a DCCF.} Signorellietal. [4] andAlmekhlafi etal. [5]treated rup-turedintracranial aneurysms by coilembolization usinga SolitaireTM _{stent. In our patient, we used this technique} for the endovascular treatment of DCCF. The SolitaireTM stent, which enables multiple retrievals, is a completely retrievablenewintracranialstent.Itsopenslit,closedcell designandvarying diametersfrom4to6mm,enablesthe use in tortuous and/or large vascular structures without riskofmigration[6].Balloonsandbarestentscanbeused in endovascular treatment of DCCF to avoid the risk of coil migration. We applied the retrievable stent-assisted coilingtechniquebyusingcombination ofSolitaireTM_stent andcoilembolization.Intra-operativeriskofcoilmigration andpostoperativeriskof thrombosiswereavoidedbythis way.Inaddition,afterremovalofthestentanti-thrombotic drugsarenotanymoreneeded.Webelievethat DCCFcan be safely, effectively and successfully treated with this endovasculartechnique,withdecreasedcomplicationrate.

Pleasecitethisarticleinpressas:FatihNasO,etal.UseofSolitaireTM_{retrievablestent-assistedcoilingtechniquefor} endovasculartreatmentofpost-traumaticdirectcarotidcavernousfistula.DiagnosticandInterventionalImaging(2016), http://dx.doi.org/10.1016/j.diii.2016.03.002

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2 LettertotheEditor

Figure1. a:carotidcavernousfistulaassociatedwiththesuperiorophthalmicveincommunicatingwiththecavernoussinusintheclinoid

segmentoftheleftinternalcarotidartery(ICA);b:placementofExcelsior1018microcathetersintothecavernoussinusthrougharterialand venoussides;c:advancementofProwlerSelectPlusmicrocatheterintotheleftmiddlecerebralartery;d:embolizationofthecavernous sinuswithcoilsofvarioussizesafterintroducingaSolitaireTM_{stentintothecarotidcavernousfistulaintheleftICAwiththehelpofProwler} SelectPlus.

Figure2. a:cavernoussinusandsuperiorophthalmicveinfillingfromtheleftinternalcarotidartery(ICA)throughthecarotidcavernous

fistulaisshownbydigitalsubtractionangiography(DSA)performedafterendovasculartreatment;b:totalclosureofthecarotidcavernous fistulaintheclinoidsegmentoftheleftICAisshownbythecontrolDSAperformedonemonthafterendovasculartreatment.

Pleasecitethisarticleinpressas:FatihNasO,etal.UseofSolitaireTM_{retrievablestent-assistedcoilingtechniquefor} endovasculartreatmentofpost-traumaticdirectcarotidcavernousfistula.DiagnosticandInterventionalImaging(2016), http://dx.doi.org/10.1016/j.diii.2016.03.002

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Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest.

References

[1]NadarajahM,PowerM,BarryB,WenderothJ.Treatmentofa traumatic carotid-cavernous fistulabythesole useofa flow divertingstent.JNeurointervSurg2012;4:e1.

[2]Saeed KilaniM, IzaaryeneJ, Cohen F,Varoquaux A, Gaubert JY, Louis G, et al. Ethylene vinyl alcohol copolymer (Onyx®_{) in peripheral interventional radiology: indications,}

advantages and limitations. Diagn Interv Imaging 2015;96: 319—26.

[3]YuY,LiQ,HuangQ,ZhangY,FangY,XuY,etal.Embolization of directcarotidcavernousfistulawithOnyx andcoils under transarterial balloon protection. Cardiovasc Intervent Radiol 2014;37:679—85.

[4]Signorelli F, Gory B, Turjman F. Temporary Solitaire stent-assisted coiling: a technique for the treatment of acutely rupturedwide-neckintracranialaneurysms.AJNRAmJ Neuro-radiol2014;35:984—8.

[5]Almekhlafi MA, Hockley A, Wong JH, Goyal M. Temporary Solitaire stent neck remodeling in the coiling of ruptured aneurysms.JNeurointervSurg2013;5:76—8.

[6]BuyukkayaR,HakyemezB,ErdoganC.Retrievablestent tech-nique and coil embolization of high-flow iatrogenic cervical vertebralarteriovenous fistula:technical note.Vasc Endovas-cularSurg2013;47:648—51.

O.FatihNasa_{,∗,R.Buyukkaya}b_,E.Kacarc_,

C.Erdogana_,B.Hakyemeza

a_{UludagUniversity,FacultyofMedicine,} DepartmentofRadiology,Bursa,Turkey b_{DuzceUniversity,FacultyofMedicine,} DepartmentofRadiology,Duzce,Turkey c_{AfyonKocatepeUniversity,FacultyofMedicine,} DepartmentofRadiology,Afyonkarahisar,Turkey ∗_{Correspondingauthor.} E-mailaddresses:omerfatihnas@gmail.com (O.FatihNas),rbuyukkaya@gmail.com (R.Buyukkaya),dremrekacar0258@hotmail.com (E.Kacar),cerdogan@uludag.edu.tr(C.Erdogan), bhakyemez@uludag.edu.tr(B.Hakyemez)

http://dx.doi.org/10.1016/j.diii.2016.03.002

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