Transarterial Treatment of Direct Carotid Cavernous Fistulas with the Assistance of Undetachable Balloons

Directed carotid cavernous fistula means high blood flow shunts between the internal carotid artery and the cavernous sinus. Obstructing the abnormal shunt between the internal carotid artery and the cavernous sinus while preserving the internal carotid artery is the key role in fistula treatment. Transarterial balloon embolization is currently the gold standard treatment for most of the carotid cavernous fistulas. But there are still some technical difficulties in the use of detachable balloon to treat carotid cavernous fistulas. Here, we describe undetachable balloon-assisted technique in the embolization of three patients who got complete immediate occlusion of the shunt and preserved the internal carotid artery at the same time. 1. Introduction Directed carotid cavernous fistula (CCF) means high blood flow shunts between the internal carotid artery (ICA) and the cavernous sinus (CS). Trauma is the chief reason of this kind of disease. Obstructing the abnormal shunt between the ICA and the CS while preserving the ICA is the key role in CCF treatment. Detachable balloon technique is an effective way in CCF treatment. But it does not always work. In this paper, we report our experiences in embolization of CCF using detachable balloon with the assistance of undetachable balloon. 2. Case Presentation Sixteen patients suffering from CCF were treated with detachable balloons in our department from January 2009 to December 2011. Three of the 16 patients were treated with the assistance of undetachable balloons. All the patients were demonstrated by angiography. We tried to occlude the CCFs with detachable balloons via the arterial approach. An 8F guiding catheter was placed in the cervical part of the parent ICA. A detachable balloon (gold valve balloon, Nycomed, Paris, France) was mounted at the tip of the balloon catheter (Balt, France). And then the balloon was advanced to the ICA through the 8F guiding catheter. The balloon was inflated to occlude the opening of the fistula after passing through the orifice. An assistant undetachable balloon (HyperGlide, ev3, USA) was employed at the following circumstances. The detachable balloon could not pass through the orifice of the fistula or the inflated detachable balloon retracted to the ICA. At the first circumstance, an undetachable balloon was introduced to the distal part of the ICA (distal part of the orifice of the CCF). The ICA was temporarily obstructed after inflating the undetachable balloon. The detachable balloon was successfully placed into the cavernous sinus because the orifice was the mainly