Journal of Neurology, Neurosurgery, and Psychiatry, 1978, 41, 996-1000

Treatment of carotid-cavernous fistula using a

balloon-tipped intra-arterial catheterU. M. CHOWDHARY

From the Department of Neurology, St Laurence's Hospital, Dublin, Ireland

S U M M A R Y The use of a balloon-tipped intra-arterial catheter for occlusion of the carotid-cavernous fistula seems to be a simple and, by the reports published to date, very effectiveprocedure, and its usage has been without any sequelae. Successful treatment of carotid-cavernous fistulae by this method is reported in two patients.

Specific anatomical and physiological consider-ations along with certain pathological changesmake the management of carotid-cavernous fistulaa complex proposition. The fistula shunts bloodfrom the high pressure arterial system into the lowpressure venous system. Consequently, collateralvessels open, and the draining venous channelsdilate.The carotid-cavernous fistula arises from the

intracavernous part of the internal carotid arteryor from one of its branches, the meningohypo-physeal, the capsular, and the artery to the inferiorcavernous sinus, which communicate extensivelywith each other and provide multiple sources forthe fistula. Flow from the contralateral side andfrom the basilar system through the circle ofWillis may provide additional sources of supply.

In January 1976, when we admitted a patientwith a carotid-cavernous fistula and pulsatingexophthalmos, we looked for a safer and simplersurgical procedure than those used previously, andnoted the technique of occlusion of the fistula bythe use of a balloon-tipped intra-arterial catheter.Reports by Prolo and Hanbery (1971), Markham(1974), Picard et al. (1974), Serbinenko (1974),and Debrun et al. (1975a), showed encouragingresults with this procedure.The aim of the procedure is the occlusion of the

carotid-cavernous fistula with a balloon-tippedintra-arterial catheter introduced into the lumenof the ipsilateral internal carotid artery, eitherthrough a small arteriotomy or by a percutaneousmethod using the Seldinger technique.

Address for reprint requests: Mr U. M. Chowdhary, Assistant inNeurosurgery, St Laurence's Hospital, Dublin 7, Ireland.

Accepted 9 June 1978

Method

The common carotid artery and its bifurcationwere exposed, and an arterial clamp was placedover the external carotid artery. A small arteri-otomy was made over the common carotid arteryat the centre of a purse-string suture for which5/0 Prolene was used. A size 3 or 4 Fogartycatheter (Fogarty et al., 1963) (Edward Labora-tories, Santa Anna, California 92706) along witha Drum Cartridge Catheter (Abbott Laboratories,North Chicago, Illinois 60064) was introducedthrough this arteriotomy for a distance of 10 cm.The tip of the drum catheter was kept 5 cm belowthe tip of the Fogarty catheter, and this was usedfor intraoperative carotid angiography to assessthe patency of the internal carotid artery after theballoon had been inflated to close the carotid-cavernous fistula.By fluoroscopic examination the balloon of the

Fogarty catheter was located. The catheter wasthen advanced slowly to bring the balloon to thepresumed site of the fistula (Fig. la,b). The Fogartyballoon was then inflated slowly with radiographiccontrast medium, through a threeway tap. Thepresence or absence of a bruit was noted. Someadjustment was needed to achieve cessation of thebruit which was regarded as evidence of occlusionof the carotid-cavernous fistula. An intraoperativeangiogram was done to determine the patency ofthe internal carotid artery. The threeway tap wassecurely closed. The drum cartridge catheter wasthen withdrawn, the neck wound was sutured, andthe proximal end of the Fogarty catheter wastaped to the chest.

Periodical auscultation was carried out to detectthe presence or absence of a bruit. Regular check

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Treatment of carotid-cavernous fistula uising a balloon-tipped intra-arterial catheter

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/I INTERNEAL CAROTIV/// /{ ARTERY Fig. 1 Schematic drawings of the operative/(ftechnique.

CLAMP

ARTERIOTOMYA RE TM

FOGARTYCATtHE TEER , |7I

COMMON CAROTID ARTERVCATHETER J

1 FOGARTY CATHETER

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radiographs of the skull were taken to see theposition and state of inflation of the balloon. Onthe fifteenth day after operation the neck woundwas reopened. The catheter was amputated, andits end buried.

Case reports

CASE1A 44 year old man (AR) was involved in anindustrial accident. He regained consciousness twodays later, and complained of severe constantthrobbing headaches, absence of vision in the lefteye, and continuous noise inside his head. A bruitcould be heard over both eyes and over the lefttemple. External ocular movements were normal.Bilateral carotid angiography was done one weeklater, and showed a moderate sized left temporalintracranial extracerebral collection of blood witha traumatic dural arteriovenous fistula on themiddle meningeal vessel at the level of the pterion.A carotid-cavernous fistula on the left side withretrograde filling of the superior ophthalmic veinand the pterygoid venous plexus was also shown(Fig. 2).The left extradural haematoma was evacuated

through a temporal craniectomy. The dural arterio- Fig. 2 Case 1 Left carotid angiograms showing thevenous fistula was not touched. His headache and carotid-cavernous fistula and the traumaticthe noise inside the head persisted. arteriovenous fistula on the middle meningeal arteryThrough an arteriotomy of the left common (upper arrow).

carotid artery a number 3 Fogarty catheter wasintroduced and placed, under fluoroscopy, at the

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presumed site of the carotid-cavernous fistula.This patient specifically requested general anaes-thesia. With full inflation of the balloon the bruitstopped. An intraoperative angiogram showedobliteration of the lumen of the internal carotidartery and of the carotid-cavernous fistula.For 36 hours after this procedure the patient

remained well, free of headache and the noiseinside the head. No bruit could be heard. Thesymptoms then returned, and the bruit could beheard again. Check radiography of the skull failedto show the balloon. The neck incision was re-opened, and the catheter was removed. Theballoon was found to have burst. The procedurewas repeated with a number 4 Fogarty catheter.The carotid-cavernous fistula was obliterated suc-cessfully. The balloon also occluded the lumen ofthe internal carotid artery (Fig. 3). Periodicalcheck radiographs of the skull showed continuedinflation of the balloon at the original site. Hisheadache, noise inside the head, and the bruitremained absent. On the fifteenth day after oper-ation, the Fogarty catheter was amputated. Follow-

Fig. 3 Case 1. Left intraoperative carotid angiogramshowing occlusion of the carotid-cavernous fistulaand internal carotid artery. Upper arrow shows thecontrast-filled Fogarty balloon at the site of thecarotid-cavernous fistula. Lower arrow shows theoccluded internal carotid artery.

U. M. Chowdhary

up studies during the last 15 months have shownhim to be symptom-free and without any bruit.Radiographs of the skull taken 12 months afterthe procedure showed a small amount of residualdye in the balloon (Fig. 4).

CASE 2A 39 year old man (ML) was admitted complainingof diminished vision of the right eye, noise insidethe head, frequent bitemporal headaches, doublevision, and loss of smell sensation for the past threeyears. Three years ago he had sustained injuriesto the head, and was unconscious for three weeks.He had a past history of psychiatric illness andhospitalisation.

Neurological examination revealed anosmia,visual acuity of 6/9 on the right and 6/6 on theleft side, proptosis of 6 mm on the right side withvisible pulsations of the eyeball. Intraocular pres-sure was 26 mmHg on the right side and 20 mmHgon the left. The fundi showed some venous con-gestion on the right side. There was restriction ofabduction of the right eye. A bruit was heardover both eyes, and over the right temporal region.

Bilateral carotid angiography showed a carotidcavernous fistula on the right side with rapidopacification of the cavernous sinus via the proxi-mal limb of the carotid syphon.A size 4 Fogarty catheter was placed at the pre-

sumed site of the carotid-cavernous fistula through

Fig. 4 Case 1. Plain lateral skull radiograph showingthe residual contrast material in the Fogarty balloon12 months after surgery.

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Treatment of carotid-cavernous fistula using a balloon-tipped intra-arterial catheter

an arteriotomy of the right common carotid artery.The procedure was done under general anaesthesiabecause the patient refused to co-operate underlocal anaesthesia. On inflating the balloon thebruit stopped. An intraoperative right carotidangiogram showed that the internal carotid arteryand the carotid-cavernous fistula were occluded.Periodical check radiographs of the skull showedcontinued inflation of the balloon at its originalsite. On the fifteenth day after operation theFogarty catheter was amputated. The bruit, bothsubjectively and objectively, had remained absentall through this period. The chemosis and proptosisof the eye ceased. He acquired full ocular move-ment. He was discharged on the twentieth post-operative day. He failed to attend the follow-upclinic.

Discussion

Ten cases where obliteration of a carotid-cavernousfistula was done by an intra-arterial ballooncatheter have been reported in the Englishliterature. In addition, Serbinenko from Moscow,published a paper in August 1974, in which hereported treating 38 patients by this method withsuccessful outcome in all but two patients. Detailsare not given in this report but the outcome iscertainly impressive. In his 10 cases, and the twopatients reported here, the outcome was entirelysuccessful. The internal carotid artery was oc-cluded in all but one. No neurological deficit wasnoted in any of these patients (Table).The tolerance of an implanted Fogarty balloon

has been shown in humans by Prolo and Hanbery(1971) and Debrun et al. (1975b).

Closure of a carotid-cavernous fistula with aballoon-tipped intra-arterial catheter is a simpleand effective procedure. Ideally, the balloonshould obliterate only the fistula and should leavethe lumen of the internal carotid artery patent,but it seems that the risk of neurological deficitfrom obliteration of the ipsilateral carotid flow isnot high. As the lumen of the ipsilateral carotid

Table Reports of treatment of carotid-cavernousfistula by balloon-tipped intra-arterial catheter

Author Number Result Carotid Sequelaeofcases circulation

Prolo and Hanbery (1971) I Cured Occluded NoneMarkham (1974) 2 Cured Occluded NonePicard et al. (1974) 5 Cured Occluded NoneDebrun et al. (1975a) 2 Cured One occluded NoneTotal 10 Cured Occluded in None

all but one

Serbinenko (1974) 38 36 No detailcured available

artery is occluded along with the occlusion of thefistula, "steal" of blood from the contralateralinternal carotid and through the circle of Willisstops, and cerebral perfusion remains adequate.This may explain the absence of cerebral is-chaemia. A further development has been reportedby Debrun et al. (1975b) where they used an inflat-able and released intra-arterial balloon techniqueto occlude the carotid-cavernous fistaula.The procedure can be done under local anaes-

thesia (Picard et al., 1974; Debrun et al., 1975a)especially if the catheter is introduced percu-taneously through a Seldinger needle, thus enablingmonitoring of cerebral functions during the pro-cedure. We used general anaesthesia in bothpatients because of special circumstances.

Introduction of the catheter through an openarteriotomy was preferred as we wanted intra-operative angiography to determine the patencyof the internal carotid artery. The danger of aleaking or burst balloon is infrequent but a dis-tinct possibility (Markham, 1974), and hence thewhole of the Fogarty catheter was left in situ for15 days, and frequent check radiographs weredone to monitor the state of inflation of theballoon and its position. In our first patient thefirst implanted balloon burst at about 36 hourspostoperatively. This was shown by the recurrenceof the bruit and by the absence of the contrastmedium filled balloon on the subsequent checkradiograph of the skull.

I would like to thank Mr P. C. Carey and Mr J. P.Lanigan, Consultant Neurosurgeons, St Laurence'sHospital, Dublin, for allowing me to treat andreport their patients.

References

Debrun, G., Lacour, P., Caron, J. P., Hurth, M.,Comoy, J., Keravel, Y., and Labont, G. (1975a).Experimental approach to the treatment of carotid-cavernous fistulas with an inflatable and isolatedballoon. Neuroradiology, 9, 9-12.

Debrun, G., Lacour, P., Caron, J. P., Hurth, M.,Comoy, J., and Keravel, Y. (1975b). Inflatable andreleased balloon technique: experimentation in dog-applicable in man. Neuroradiology, 9, 267-271.

Fogarty, T., Cranley, J., and Krause, R. (1963). Amethod for extraction of arterial emboli and thrombi.Journal of Surgery, Gynaecology, ana Obstetrics,116, 241-244.

Luessenhop, A., and Velasquez, A. C. (1964). Obser-vation on tolerance of intracranial arteries to cath-eterisation. Journal of Neurosurgery, 21, 85-91.

Markham, J. W. (1974). Carotid-cavernous fistulatreated by intravascular occlusion with a ballooncatheter. Journal of Neurosurgery, 40, 535-538.

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Picard, L., Lepoise, J., Montaut, J., Hepner, H.,Roland, J., Guyonnaud, J. C., Jacob, F., andAndre, J. M. (1974). Endarterial occlusion ofcarotid-cavernous fistulas using a balloon-tippedcatheter. Neuroradiology, 8, 5-10.

Prolo, D. J., and Hanbery, J. W. (1971). Intraluminal

U. M. Chowdhary

occlusion of a carotid-cavernous sinus fistula with aballoon catheter; technical note. Journal of Neuro-surgery, 35, 237-242.

Serbinenko, F. A. (1974). Balloon catheterisation andocclusion of major cerebral vessels. Journal ofNeurosurgery, 41, 125-145.

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